[3 MIN READ]
Correct patient identification has long been at the top of the list regarding safety.
A recent TSG article by Dr. Tom Syzek entitled “Medical Errors, Communication, Teamwork and End of Life: Lessons from Angola” speaks to the importance of correct patient identification and the safety implications surrounding it. This article dovetails nicely with the new 2019 Joint Commission National Patient Safety Goal (NPSG) regarding newborn identification, so I thought this would be the perfect opportunity to keep the conversation relevant and on-topic by addressing this new NPSG.
Hospitalized newborns are a vulnerable population at considerable risk for misidentification. Several unique features of the newborn population lead to misidentification:
Furthermore, well-known misidentification errors such as wrong patient/wrong procedure have resulted in many errors, including:
All these errors have the potential to cause patient harm and parental distress. A reliable identification system is necessary to prevent these types of serious errors and prevent harm to the newborn; hence, the birth of this safety initiative.
The need for updated and improved newborn identifiers was recognized by the AAP and other leaders in the field of safety. Gray et al. found that similar medical record numbers followed by similar or identical surnames made up the bulk of misidentification errors. Heightened awareness to this issue provided the impetus for much needed scrutiny of current practices. After research of the literature, public review, and engaging discussion the safety leaders developed the National Patient Safety Goal (NPSG.01.01.01).
Effective January 1, 2019, all hospitals caring for newborns will be required to use at least two patient identifiers when providing care, treatment and services to newborn infants.
Examples of methods to prevent misidentification as cited by the NPSG may include the following:
Vigilance for accurate patient identification is a quality and safety issue that should be embedded into our daily hospital routines. The busyness of hospital routines such as infant feedings, circumcision, cardiac screens, hearing screens, bilirubin assessment and lab draws should not undermine the importance of correct patient identification. Everyone working with newborns is responsible to ensure that misidentification does not happen and that safety is always maintained.