So-called wrong patient orders have long been a bigger risk in the
neonatal intensive care unit (NICU) than in general pediatrics
wards, and these mix-ups are more common when newborns haven't yet
been named or have a name very similar to another hospitalized baby,
researchers note in JAMA Pediatrics.
But research to date hasn't offered a clear picture of whether
siblings in multiple births are more likely to be subject to wrong
patient orders.
For the current study, researchers examined data on 10,819 infants
treated at six NICUs run by two healthcare systems in New York City
between 2012 and 2015. Most of these babies, 85.5%, were singleton
births; 14.5% were multiples like twins or triplets.
Multiples in the NICU were 75% more likely to have wrong patient
orders than singletons.
"The current study is the first to demonstrate that multiple births
have a significantly greater risk of order errors than singleton
births, and that the excess risk is attributable to errors between
siblings receiving care in the NICU at the same time," said Dr.
Jason Adelman, lead author of the study and chief patient safety
officer at NewYork-Presbyterian Hospital/Columbia University Irving
Medical Center in New York City.
"These results were remarkably consistent across two large health
systems, suggesting a more widespread rather than an isolated
problem," Adelman said by email.
To assess wrong patient orders, researchers focused on how often
clinicians entered requests for medicine or treatments or tests in
electronic medical records - and then retracted the request within
10 minutes and placed an identical request for a different NICU
patient. This so-called retract and reorder (RAR) process suggests
that clinicians noticed an error and went into the records to fix
it, the study team notes.
Overall, there were 66 RAR events for every 100,000 orders made for
multiples, compared with 41.7 RAR events for every 100,000 orders
made for singletons, the study found.
RAR events that involved switching orders from one baby to an infant
that wasn't a sibling happened roughly as often as RAR events for
singleton births.
[to top of second column] |
This suggests that most of the added risk of ordering mistakes was
because babies were multiples.
The risk also increased with the number of siblings in the NICU.
Wrong patient orders happened in 1 in 7 sets of twins and 1 in 3
sets of multiples with three or more babies.
"Babies of multiple births can be confused as the ability to tell
twins apart soon after birth, especially for very premature twins,
can be really hard, and they usually have the same last name," said
Dr. Gary Freed, author of an editorial accompanying the study and a
professor of pediatrics at the University of Michigan in Ann Arbor.
"The risk from wrong patient orders is that babies may not get the
medicines or treatments they need and/or may get ones they do not
need that can be harmful," Freed said by email.
Part of the problem is that hospitals often use names or codes to
identify infants that may only differ by a single letter or digit
for multiples, Adelman said.
"This is largely a hospital systems issue, so we recommend that
hospitals use given names in their electronic health record systems
for all newborns when available at the time of the birth," Adelman
said.
"In addition, we encourage parents, particularly those expecting
multiple births, to choose names to be ready to use when the babies
are born," Adelman added. "If for cultural or religious reasons
parents prefer not to choose or share the babies' given names, we
suggest they select distinctive nicknames" that can later be changed
to given names on their birth certificates.
SOURCE: https://bit.ly/30GXjYp and https://bit.ly/2ZBihdK JAMA
Pediatrics, online August 26, 2019.
[© 2019 Thomson Reuters. All rights
reserved.] Copyright 2019 Reuters. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.
Thompson Reuters is solely responsible for this content. |