Switched at Birth?
Imagine one of the worst nightmares that parents could experience: another baby is mistaken for their own during the course of care at a hospital or, worse, during the discharge process. Unfortunately, it’s not inconceivable, as these parents know:
- In 2008, two infants were switched during circumcision procedures at a hospital in Illinois.
- In 2012, a newborn was breastfed by the wrong mother at a Minneapolis hospital.
- In 2018, a couple in West Virginia claimed that a local hospital gave them the wrong baby.
While incidents like these are rare, infant mix-ups at hospitals continue to be a potential risk. A study out of Pennsylvania found an average of nearly two newborn misidentification events reported daily. These are nightmares that parents should never experience.
Of course, when it comes to patient identification, babies do present unique challenges. After all, they can’t tell you who they are. And, as the Pennsylvania Patient Safety Authority noted, “they often share similar or identical birth dates, similar medical record numbers, and, in the case of twins and multiple births, common surnames.” It’s difficult to fit and secure wristbands on their tiny wrists. They wiggle and move about, making wristbands difficult to read.
This is further complicated by the fact that many hospitals use naming conventions that can create confusion. A recent survey by the American Academy of Pediatrics found that, of 339 neonatal intensive care units, 81.7 percent used nondistinct naming conventions such as “BabyBoy” or “BabyGirl”.
The Joint Commission: Looking out for patient safety
Since 2002, the National Patient Safety Goals (NPSG) set by The Joint Commission, the not-for-profit organization that accredits and certifies nearly 21,000 healthcare organizations and programs in the United States, have established standards for ensuring patient safety in all healthcare settings. At the top of the NPSG agenda remains the mandate to “use at least two patient identifiers when providing care, treatment, and services.”
Though the two-identifier mandate was established well over a decade ago, a January 2019 iteration of the NPSG included a new Element of Performance that requires Joint Commission-accredited hospitals that provide labor and delivery services to use specific naming conventions to identify newborn patients.
Specifically, the naming conventions must include:
- Mother’s first and last name and the newborn’s gender
- A second identifier added to banding with two body-site identifications and barcoding
The mandate also recommends that hospitals alert staff to these new requirements in situations in which there are newborns in the facility with similar names.
How to Confirm That Your Newborn Identification Solution Meets New Mandate Requirements
Barcoded wristbands have long served as the primary patient identification tool for hospitals. However, it is important to remember that not all wristbands are the same. When evaluating whether or not your hospital’s existing patient identification system complies with this new newborn identification mandate, you should thoroughly assess your wristbands to ensure they feature critical attributes, such as:
- A design and shape that enables them to lie flat on the wrist for easy scanning.
- Soft material that ensures infant comfort.
- Accommodation for reading swaddled infants.
- Lamination that protects patient data (text and barcodes) from moisture and hand sanitizers.
- Adhesive closures to prevent tampering.
- Wristband extenders to accommodate a wide range of wrist sizes.
- A foolproof system for providing matching wristbands to the mother or birthing partner.
If your current wristbands do not meet all of these criteria, then it may be time to consider alternative solutions that satisfy both baby and mother identification (and comfort) requirements.
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Editor’s Note:
Did you know that Zebra’s new LaserBand2 Labor and Delivery Wristband patient identification system were designed to ease compliance with the Joint Commission’s new mother-baby identification mandate? You can learn more about these wristband solutions here.
Shannon Swanson
Shannon Swanson is Manager, Product Management, Healthcare Supplies Portfolio at Zebra Technologies.
