Twins, Triplets Have Higher Risk of Medical Mix-Ups in Neonatal ICUs

By Lisa Rapaport

August 30, 2019

(Reuters Health) - Doctors are much more likely to make mistakes ordering medicines or treatments for babies in the ICU when these infants are twins or triplets than when they are they singletons, a U.S. study suggests.

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 noted August 26 online 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.

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.

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 Pediatr 2019.

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