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

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.