The virtual neonate in The Neonatal Intensive Care Unit: When twin number three adds up to error not imagination

Amir Kushnir, Elena Chulsky, Robyn Rubin, Daniel Zohar, Shay Barak

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: During the administrative admittance of extreme premature twin neonates to the Hospital Information System (HIS), at an Israeli government general hospital, a third virtual baby was mistakenly admitted in addition to the twins. The third virtual baby's records were in department occupancy and transactions were performed in the HIS, such as "admittance" to Neonatal Intensive Care Unit (NICU), being appended to a mother as well as clinical orders. Methods: Once noticed, the records of the third virtual baby were merged in the system with the second correct twin (Baby II), whose records were also in the department occupancy list. Results: An error occurred in the interface whilst merging the records, and patient demography was not updated for clinical orders for Baby II. As a result, all new clinical orders for Baby II carried the non existing third baby's identity. Conclusions: We emphasize that it is advisable to register all newborns as early on in life whilst still in the delivery room, with a permanent identification number as opposed to a temporary identification number to avoid any mismatching if patients records are to be merged or updated. Furthermore, steps that could help prevent such an event could be additional administrative staff to register newborns. However, we conclude, that it would be most helpful to introduce a Radio Frequency Identification (RFID) system based on a permanent identity number. If any discrepancies in patient information are detected, an alarm will be triggered during transfer of the baby from the delivery room to the designated Department. A RFID receptor is located at the exit of the delivery room.While most literature available regarding Hospital Information Technology (HIT) and patient safety, mainly discusses mismatching of patients during medication and laboratory testing not much literature regarding the process of registering newborns as a source of patient mismatching has been found. The authors feel that there is a need to further investigate this aspect as it is a source that can affect not only accuracy in the Electronic Patient Record (EPR) but furthermore has the impact to change the course of a life and set tone for that person's future.

Original languageEnglish
Pages (from-to)683-690
Number of pages8
JournalInternational Journal of Medical Informatics
Issue number9
StatePublished - Sep 2014
Externally publishedYes


  • Electronic patient records
  • Human error
  • Information technology
  • Pediatrics


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