NICU Naming Conventions Cause Wrong-Patient Errors

baby
Prior research indicates that as much as 76 percent of retracted orders in the NICU are a result of patient misidentification. REUTERS/Dani Cardona

It's a plotline you've seen on half a dozen TV shows: A baby born premature or with significant complications is rushed from the delivery room to the neonatal intensive care unit (NICU). Time is of essence and so the hospital staff will temporarily name the newborn based on its gender and family's last name—leading to tags like Babygirl Smith and Babyboy Rodriguez.

It's also very much a real-life scenario. A survey of 339 medical institutions conducted by the American Academy of Pediatrics found that 82 percent use these types of simple naming conventions in the NICUs. The problem, though, is that this conventional naming can lead to devastating consequences, including misidentity that may even result in a baby going home with the wrong family.

A study published this week in the journal Pediatrics looked at the rates of wrong-patient errors that occur with this classic naming convention and compared the outcomes to a newer formula that also uses the mother's first name. The researchers found that adding this simple additional identifier to generate names such as Jennifersgirl Smith or Stephaniesboy Rodriguez could reduce the number of NICU mix-ups by as much as 40 percent.

"Replacing a nondistinct naming convention with one that uses distinct names is a simple and effective intervention that is not costly, labor intensive, or dependent on new technology and may be easily implemented in most NICUs," the researchers write in their study.

In July 2013, Montefiore Medical Center implemented this newer naming convention, and trained all clerical staff to use it. Then researchers evaluated the rates of newborn mix-ups before and after implementing the new naming protocols for the NICU. In particular, the researchers kept track of the number of orders made by a clinician for patient that were retracted 10 minutes later. They compared the rates of retracted orders of the same clinicians with and without the new naming convention, and found a reduction of these errors with the new naming protocols. Prior research indicates that as much as 76 percent of retracted orders in the NICU are a result of patient misidentification.

The researchers say they conducted the study primarily to evaluate how errors can creep into electronic medical records, but the study also showed that a number of other alarming problems emerge as a result of the naming conventions, such as associating medical imaging tests or pathology test results with the wrong infant, or even administering blood products to the wrong baby.

"One particularly concerning wrong-patient error unique to NICUs and hospital nurseries is feeding a mother's expressed breast milk to the wrong infant," the researchers write in their study. "The use of distinct patient names printed on breast milk bottles may also decrease the risk of a nurse removing the wrong bottle from a nursery refrigerator."

NICU Naming Conventions Cause Wrong-Patient Errors | Tech & Science