Skip Navigation U.S. Department of Health and Human Services
Agency for Healthcare Research Quality
Archive print banner

Feature Story

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

NICU babies are frequently at risk for misidentification

Neonatal Intensive Care Unit (NICU) babies often share similar or similar-sounding last names or similar medical record numbers (MRNs) with other babies receiving care in the same NICU on the same day. The potential confusion created by these similarities contributes significantly to the risk of patient identification errors in the NICU. An infant could be given a medication, procedure, or mother's expressed breast milk intended for another infant, perhaps with adverse consequences. A study supported in part by the Agency for Healthcare Research and Quality (HS11583) found that during one calendar year, there was not a single day without at least one pair of patients at risk for misidentification. On average, 26 percent of NICU babies were at risk for being mistaken for another baby on any given day.

Researchers measured the potential for misidentification among NICU infants resulting from patient name and MRN similarities based on a listing of infants who received care in one NICU during 1 year. A patient was considered at risk for misidentification when the index infant shared a surname, similar-sounding surname, or similar MRN with another infant who was cared for in the NICU on that day.

The mean number of patients who were at risk on any given day was 17, representing just over 50 percent of the average daily census (33.4 babies). During the entire year, the risk of misidentification ranged from 20.6 percent to a high of 72.9 percent of the average daily census. The most common causes of misidentification risk were similar appearing MRNs (44 percent of patient days), identical surnames (34 percent), and similar-sounding names (9.7 percent).

These findings underscore the need to reconsider the methods used for NICU patient identification, assert the researchers. Since the physical appearance of NICU infants isn't as helpful as in older patients, NICU clinicians must rely on standardized patient wristbands for identification purposes. Errors in wristband content or use are frequent, and missing wristbands are common.

More details are in "Patient misidentification in the neonatal intensive care unit: Quantification of risk," by James E. Gray, M.D., Gautham Suresh, M.D., Robert Ursprung, M.D., and others, in the January 2006 Pediatrics 117(1), pp. 43-47.

Return to Contents
Proceed to Next Article

The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care