Giving newborns distinct names cuts errors

Dr. Jason Adelman had long suspected that the naming system most hospitals use to temporarily identify newborns in the neonatal intensive-care unit could lead to confusion and wrong-patient errors.

“We knew it was an issue, but we didn't have a good way to measure it,” said Adelman, the patient-safety officer at Montefiore Health System in New York City.

Babies in NICUs are often assigned a non-distinct name such as “Babygirl” or “Babyboy,” followed by their mother's last name. That naming convention is problematic because the distinguishing patient identifier—the baby's last name—is at the end, said Dr. William Southern, Montefiore's chief of hospital medicine.

“You can imagine being a provider and looking at a computer screen with Babygirl, Babygirl, Babyboy, Babyboy all the way down the list,” Southern said. Add to the mix babies with common last names such as Smith and Jones, and there could be even greater potential for errors, he added.

More than 80% of 339 NICUs surveyed by Adelman and the American Academy of Pediatrics reported using non-distinct names.

In July 2013, Montefiore introduced a new naming convention that incorporated the mother's first name, the baby's gender and the mother's last name, such as Wendysgirl Jones or Catherinesboy Jackson. For multiple births, a number was added to distinguish siblings, as in 1JudysgirlSmith and 2JudysgirlSmith.

To measure whether the new system reduced errors, Adelman and his colleagues used the retract-and-reorder (RAR) tool, a method developed at Montefiore that identifies orders placed for a patient, retracted within 10 minutes, then placed for a different patient.

The rate of RAR events dropped 36.3% in the year following the adoption of the new naming convention, compared with the 12 months prior to the intervention, according to the study results published in July in the journal Pediatrics.

“We were surprised that the reduction was so dramatic, especially because this study came on the heels of another hospital-wide intervention aimed at reducing wrong-patient errors,” Southern said. “We were starting from a point where errors had already been significantly reduced. The reduction was on top of that.”

Dr. Michele Walsh, interim chair of pediatrics at Rainbow Babies and Children's Hospital in Cleveland, said her hospital has used a distinct naming convention incorporating mothers' first and last names for over a decade, ever since implementing an electronic health record. “The (EHR) exacerbated the potential for errors because the screens didn't have enough character room for full last names,” she said.

Walsh urged other hospitals to use distinct names for babies in the NICU. And as soon as families decide on a name, it should be changed in the EHR, she said.

Dr. Tonse Raju, chief of pregnancy and perinatology at the National Institute of Child Health and Human Development of the National Institutes of Health, applauded the Pediatrics study for not only describing the risk, but also recommending a solution. Non-distinct names pose a risk not only in the NICU, but in the nursery as well, he said.

“I was in neonatology for 30 years in Chicago, and I saw babies getting the wrong medications and wrong babies getting sent out for X-rays,” Raju said. “We even had one instance where the wrong baby got a CT scan.”

Adelman acknowledged that the errors measured by the RAR tool were near-misses that did not lead to harm. But he said it's understood in the patient-safety field that near-misses and errors that cause patient harm have the same causal pathway. “Because there are so many more near-misses than errors that actually reach the patient, you study interventions for near-misses and you make the assumption that they also will work for errors that cause harm,” he said.

The study is a before-and-after trial, so some of the reduction in wrong-patient errors could have been the result of other efforts, although the researchers don't think that's the case, Adelman said. He hopes to eventually conduct a multisite randomized controlled trial of the new naming convention that will look more closely at multiples and other potentially high-risk patient groups.

In the meantime, he said, the study clearly shows that there is a danger associated with non-distinct names, and that a distinct naming convention lowers risks. “Hospitals don't have to use our exact system, although I do think it's convenient and easy to use the mother's first name,” Adelman said. “They just need to use one that adds a level of distinction.”