Distinct Naming Convention For Babies In Neonatal Intensive Care Unit Significantly Reduces Wrong-Patient Errors, Research Shows

Study Published in Pediatrics Highlights Low-Cost, Low-Tech Approach to Identification Can Improve Wrong-Patient Errors by Almost 40 Percent

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Montefiore Health System

Jul 13, 2015, 03:56 ET

NEW YORK, July 13, 2015 /PRNewswire-USNewswire/ -- Traditionally, babies in the Neonatal Intensive Care Unit (NICU) are temporarily identified by gender and last name, such as Babyboy Jackson or Babygirl Smith, but this naming configuration can result in wrong-patient errors for the fragile newborns. A study published today in the journal Pediatrics found that a more sophisticated naming convention that utilizes the mother's first name, the baby's gender and last name, such as Wendysboy Jackson or Catherinesgirl Smith, can reduce wrong-patient errors by almost 40 percent.

Investigators at Montefiore Health System and the Children's Hospital at Montefiore (CHAM) conducted a first-of-its-kind study that compared wrong-patient error rates pre-intervention -- where babies were named, as most currently are in U.S. NICUs, by gender and last name -- and post-intervention -- where babies were named with the distinct naming convention. Each intervention lasted for one year and included more than 1,000 babies.

"It's not uncommon for babies in the NICU to have similar last names, which can easily cause confusion," said Jason Adelman, M.D., M.S., lead author, patient safety officer at Montefiore and assistant professor, Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine. "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."

To compare wrong-patient errors, researchers used the Retract-and-Reorder (RAR) tool which identifies orders placed on a patient that are retracted within 10 minutes, and then placed by the same clinician on a different patient within the next 10 minutes. Prior research by the same investigators suggests that 76.2 percent of RAR events represent wrong-patient errors. Near misses caught by the clinician before they reach the patient may include reading imaging tests or pathology specimens for the wrong patient, or administering breast milk to the wrong infant.

"Every year thousands of babies require care in NICUs throughout the U.S.," said Judy Aschner, M.D., physician-in-chief, CHAM, professor and Michael I. Cohen, M.D., University Chair of Pediatrics at Einstein, co-author and neonatologist. "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."

Previous research by the authors showed that of 339 NICUs surveyed nationwide, 81.7 percent reported using non-distinct naming conventions.

"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," said senior author William Southern, M.D., M.S., chief, Division of Hospital Medicine at Montefiore and professor of Clinical Medicine at Einstein. "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."

About Montefiore Health System
Montefiore is a premier academic health system and the University Hospital for Albert Einstein College of Medicine. Combining nationally-recognized clinical excellence with a population health perspective that focuses on the comprehensive needs of the communities it serves, Montefiore delivers coordinated, compassionate, science-driven care where, when and how patients need it most. Montefiore consists of eight hospitals and an extended care facility with a total of 2,747 beds, a School of Nursing, and state-of-the-art primary and specialty care provided through a network of more than 150 locations across the region, including the largest school health program in the nation and a home health program. The Children's Hospital at Montefiore is consistently named in U.S. News' "America's Best Children's Hospitals." Montefiore's partnership with Einstein advances clinical and translational research to accelerate the pace at which new discoveries become the treatments and therapies that benefit patients. The health system derives its inspiration for excellence from its patients and community, and continues to be on the frontlines of developing innovative approaches to care. For more information please visit http://www.montefiore.org. Follow us on Twitter; like us on Facebook; view us on YouTube.

SOURCE Montefiore Health System