Distinct Naming Convention in NICU can Reduce Errors

NICU

Babies in Neonatal Intensive Care Units (NICU) are traditionally identified on the basis of gender and last name such as Babyboy Jackson or Babygirl Smith. However, this naming configuration has the potential to result in wrong-patient errors. 

According to a study published in Pediatrics, the use of a more sophisticated naming convention that includes the mother's first name, the baby's gender and the baby's last name (for example Wendysboy Jackson) can reduce wrong-patient errors by nearly 40 percent. 

"It's not uncommon for babies in the NICU to have similar last names, which can easily cause confusion," said Jason Adelman, MD, MS, 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."

The study, conducted by Montefiore Health System and the Children's Hospital at Monteifiore (CHAM), is the first-of-its-kind study that compares the wrong patient error rates pre-intervention (with the old system of gender and last name) with post-intervention (with the new distinct naming system).  
Both interventions lasted for a year and included more than a 1000 babies. The researchers used a Retract-and-Reorder tool (RAR) that helped identify orders placed on a patient that are retracted within ten minutes are and then placed on another patient within the next ten minutes. Previous research suggests that 76.2 percent of RAR events represent wrong-patient errors. There are near misses that are caught by clinicians just in time before patients are reached for imaging tests, pathology specimens etc. 

Judy Aschner, MD, physician-in-chief, CHAM, professor and Michael I. Cohen, MD, University Chair of Pediatrics at Einstein, co-author and neonatologist, point out that thousands of babies are admitted for care in NICUs every year and each day, healthcare providers  write dozens of orders for medications, laboratory tests and therapies for infants. All this is done while identifying these vulnerable newborns as babyboy or babygirl, a system that has tremendous potential for errors. Nearly 81.8 percent of NICUs surveyed nationwide in another research reported using non-distinct naming conventions.

Senior author William Southern, MD, MS, chief, Division of Hospital Medicine at Montefiore and professor of Clinical Medicine at Einstein highlights the need to use information technology and electronic health records to change the way things are done. Distinct naming convention should be implemented in all NICUS in the U.S. so that many wrong-patient errors could be prevented. 

Source: Montefiore Health System

Image Credit: Wikimedia Commons

Published on : Mon, 20 Jul 2015


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NICU, naming convention, new born, wrong-patient errors, distinct naming convention According to a study published in Pediatrics, the use of a more sophisticated naming convention that includes the mother's first name, the baby's gender and the baby's last name (for example Wendysboy Jackson) can reduce wrong-patient errors by nearly 40

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