Incident Reports of Naming Errors among Two Sets of Infant Twins

Newborns are at high risk for identification errors due to their inability to speak and indistinguishable features. To reduce this risk, The Joint Commission requires hospitals to use a distinct identification method for newborns. Most hospitals create medical records for newborns at birth using temporary naming conventions, resulting in patients with similar identifiers. Typically, multiple-birth infants are distinguished from their siblings by a single character (1, 2, or A, B), placing them at higher risk for identification errors, which can delay care and compromise patient safety. METHODS: We present 2 unrelated cases involving naming errors in sets of infant twins receiving care in a healthcare system using Joint Commission compliant distinct temporary naming convention. RESULTS: In the 2 cases, system failures contributed to naming errors in 2 sets of infant twins, which resulted in delayed care. In the first case, twins were inadvertently assigned the same temporary name. In the second case, an infant’s blood specimen label did not include a single character, which distinguishes a multiple-birth infant from their sibling. Further safeguards are needed to reduce this risk. These cases illustrated the potential for misidentification related to newborn naming conventions during the registration process, especially between siblings of multiple-birth infants. CONCLUSIONS: Further research is needed to determine strategies to prevent newborn identification errors. Potential strategies to reduce this risk and protect newborns include improving the design of newborn identifiers, systems-level interventions such as verification alerts, and improved registration processes.