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.