Wrong-Patient Ordering Errors in Peripartum Mother-Newborn Pairs: A Unique Patient-Safety Challenge in Obstetrics

Because maternal morbidity and mortality remain persistent challenges to the U.S. health care system, efforts to improve inpatient patient safety are critical. One important aspect of ensuring patient safety is reducing medical errors. However, obstetrics presents a uniquely challenging environment for safe ordering practices. When mother-newborn pairs are admitted in the postpartum setting with nearly identical names in the medical record (for example, Jane Doe and Janegirl Doe), there is a potential for wrong-patient medication ordering errors. This can lead to harm from the wrong patient receiving a medication or diagnostic test, especially a newborn receiving an adult dose of medication, as well as delaying treatment for the appropriate patient. We describe two clinical scenarios of wrong-patient ordering errors between mother-newborn pairs. The first involves an intravenous labetalol order that was placed for a postpartum patient but was released from the automated dispensing cabinet under the newborn's name. The medication was administered correctly, but an automatic order for labetalol was generated in the neonate's chart. Another scenario involves a woman presenting in labor with acute psychotic symptoms. The psychiatry service placed a note and orders for antipsychotic medications in the neonate's chart. These orders were cancelled shortly thereafter and replaced for the mother. These scenarios illustrate this specific patient-safety concern inherent in the treatment of mother-newborn pairs and highlight that perinatal units should evaluate threats to patient safety embedded in the unique mother-newborn relationship and develop strategies to reduce risk.