Montefiore in the News
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Montefiore in the News

NEW YORK (July 13, 2015) – 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.”