Distinct NICU newborn naming linked to reduced error

1. With the implementation of a distinct and unique naming system in neonatal intensive care units (NICU), potential wrong-patient errors were reduced by a total of 36.3%.

2. The greatest reductions in errors were seen among orders placed by house staff (interns, residents, and fellows) and in orders placed on male patients.

Study Rundown: In 2012, approximately half a million infants were admitted to NICUs in the United States, and in order to prevent delay, some hospitals may assign newborns temporary, generic first names, such as Babygirl or Babyboy. Previous research has shown that 11% of medical errors in NICUs were attributable to patient misidentification errors, but no study has examined the possible association of temporary names with wrong-patient medical errors. Authors of the current study sought to determine whether nondistinct names for newborns increase the frequency of wrong-patient errors and if unique first names could potentially decrease this problem. After the establishment of a distinct naming convention, it was estimated that potential wrong-patient errors were drastically reduced. This reduction was seen in the majority of all patient and provider subgroups analyzed. This study may be limited by the possible presence of the Hawthorne effect, inability to detect high-risk subgroups, and in that the error estimation tool used had not been specifically validated for use in the NICU. However, the results should encourage the adaptation of a more distinct and unique naming system in all NICUs in order to help reduce the occurrence of wrong-patient errors.

Click to read the study, published today in Pediatrics

Relevant Reading: Patient misidentification in the neonatal intensive care unit: Quantification of risk

Study Authors, Jason Adelman, M.D., M.S., Judy Aschner, M.D., Michael I. Cohen, M.D., and William Southern, M.D., M.S., talk to 2 Minute Medicine: Albert Einstein College of Medicine, Montefiore Medical Center.

“It’s not uncommon for babies in the NICU to have similar last names, which can easily cause confusion. Implementing a distinct naming convention is a simple and effective intervention that doesn’t require extensive resources and can be easily applied at other institutions to help prevent potentially-dangerous errors for these patients…Every year thousands of babies require care in NICUs throughout the U.S. Each day healthcare providers in the NICU write dozens of orders for medications, laboratory tests and therapies for infants whose first name is ‘babyboy’ or ‘babygirl.’ This simple and highly-effective approach to correctly identify a vulnerable newborn is an important step to ensure that each baby gets the appropriate care intended for their individual needs that helps them on the road to good health…This is an example of how health information technology and the data generated by electronic health records can be used for ground-breaking research that can immediately change the way we care for patients. If a distinct naming convention was implemented in all NICUs in the U.S., a very large number of wrong-patient errors might be prevented.”

In-Depth [cross-sectional study]: Research was conducted at Montefiore Medical Center in Bronx, New York. Researchers detected wrong-patient errors by using the Retract-and-Reorder (RAR) tool. This method highlights potential wrong-patient errors by identifying orders placed on a patient that were withdrawn within 10 minutes and then identically reordered on a different patient within 10 minutes. A total of 76.2% of RAR events were classified as wrong-patient errors according to previous research. The new distinct naming system for newborn infants included the mother’s first name, followed by the letter “s” and the gender of the child (e.g. Wendysgirl). RAR data was gathered for 1 year pre-intervention (157 857 total orders, 1115 neonates) and for 1 year post-intervention implementation (142 437 orders, 1067 neonates). Subgroups were analyzed according to patient demographics (gender, age, race/ethnicity, and insurance type) and provider characteristics (attending physician, house staff, nurse practitioners, and physician assistants). The RAR error rate decreased by 36.3% after implementation of the distinct naming system (OR 0.64, 95% CI: 0.42-0.97). Benefits were seen in almost all analyzed subgroups except attending physicians and nurse practitioners, but RAR events were reduced most in orders made by house staff (OR 0.48, 95% CI: 0.24-0.93) and in orders placed on male patients (OR 0.39, 95% CI: 0.19-0.83).

Image: CC/Flickr/Chris Sternal-Johnson

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