Adelman JS, Applebaum JR, Southern WN, et al. - In this retrospective cohort study involving 10,819 infants, researchers evaluated the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the neonatal intensive care unit (NICU) and analyzed the proportion of wrong-patient orders among multiple-birth infants and siblings (intrafamilial errors) and amongst multiple-birth infants and nonsiblings (extrafamilial errors). In comparison with singleton-birth status, multiple-birth status in the NICU was linked to a significantly increased risk of wrong-patient orders. It appears that this excess risk is due to misidentification between siblings. Among multiple-birth infants, a different naming convention as needed by The Joint Commission may give inadequate protection against identification errors. Strategies for mitigating this hazard include using names given given at birth, switching from temporary to names given when available, and allowing parents to choose names for multiple births before birth if acceptable to families.