An average of nearly two newborn misidentification events occur daily in Pennsylvania, according to estimates from the Pennsylvania Patient Safety Authority (PPSA).

Patient Safety Analyst Susan C. Wallace, MPH, CPHRM, studied identification errors in newborns and found 1,234 newborn identification events reported to the PPSA from January 2014 through December 2015.

The majority of reported events involved procedure errors such as mislabeled specimens, followed by general misidentification errors including missing or mismatched identification bands. There also were medication events and breast milk administration mistakes. Most of the events were reported as near misses that did not harm the patient, but five were reported as serious events resulting in patient harm. Those included a baby given the wrong breast milk and another who underwent circumcision without parental consent.

The errors fell into four categories: procedure errors (74%), general misidentification (10%), medication events (9%), and breast milk administration mishaps (7.2%). Ninety-eight percent of procedure errors were laboratory-related, with radiology, surgical, and respiratory comprising the rest.

The article includes examples of how newborns were misidentified. The following are three examples:

  • “Phlebotomist was in the NICU to draw blood from a baby. When she looked at the baby’s name band on the wrist it said a different name. She notified the nursing staff that it was the incorrect baby. The resident in the room stated it was the right baby. She then told them the name on the band was not the name on her requisition. The nurse checked and confirmed the baby in fact had the incorrect band on. It was removed, and the phlebotomist states the nurses were trying to figure out if another baby had the incorrect band and how to correct the mistake.”
  • “Antibiotic order faxed to pharmacy. When entering the order, pharmacist noted this patient’s weight was significantly different from the weight on the order (2.185kg vs. 0.83kg). The pharmacist found that the sticker on the antibiotic order was incorrect. There are currently two patients with the same last name.”
  • “Newborn baby boy given to incorrect mother for breast-feeding. Staff nurse realized the mix-up and went to retrieve newborn from incorrect mother. Event discovered in short period of time. After reviewing event with the incorrect mother, it was confirmed that the baby did indeed latch on to her breast. Infection Prevention notified. Event was disclosed to this baby’s birth mother and father.”

The PPSA report is available online at: