What's in a name? When it comes to newborns, there could be a medical error

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What's in a name? When it comes to newborns, there could be a medical error

A new, simple, distinct naming convention for pediatric patients could have a huge impact on patient safety

Not every baby is born with a name. Sometimes, for religious reasons, parents will wait a predetermined amount of time before naming the newborn. In other cases, the pressure is simply too much, or the baby is born premature and the parents have not yet decided on a name.

In those instances, most hospitals assign temporary names identifying the child by his or her gender and the mother's last name (e.g., Babygirl Smith).

But according to a new study, that naming convention could contribute to wrong-patient errors as clinicians navigate through a slew of similarly constructed names. Fortunately, there may be a relatively simple solution.

The study, published in the August issue of Pediatrics, looked at the impact of transitioning from a non-distinct approach to newborn identifiers (e.g., Babygirl Smith) to a distinct naming convention using the mother's first name as a unique identifier (e.g., Janesgirl Smith). Researchers utilized a "retract and reorder" (RAR) tool that tracked when clinicians mistakenly placed an order on one patient, but retracted that order within 10 minutes and then placed another order on a different patient.

Jason Adelman, MD, MS, the patient safety officer at Montefiore Medical Center in New York City and the lead author of the study, refers to RAR tool as the "oops query." Essentially, these were self-caught errors that would have been difficult to track without clinicians voluntarily reporting the error.

The RAR tool enabled Adelman and his colleagues to collect those instances without relying on self-reporting. What they found was that when they switched from a non-distinct naming convention to a distinct convention, RAR events dropped 36%, confirming what they anecdotally knew was true: Non-distinct naming leads to confusion within the neonatal intensive care unit (NICU), and in some cases, contributes to near misses or unknown medical errors.

"It's not just that we knew it was a problem?I think the NICU world at large knew it was a problem?it was just that there was no method really to do the research that we did," he says. "What made our research possible was the development of an automated measure that captures orders placed on the wrong patient."


Reducing risks

Although the Pediatrics study stopped short of identifying ways this naming change prevented medical errors, Adelman says it's easy to see how problematic it could be, particularly if a physician inputs an order for the wrong patient, but never catches the mistake.

For example, mismanagement of expressed breast milk has been previously identified as a problem in some hospitals. In 2007, the Pennsylvania Patient Safety Authority released an advisory listing the risk factors of infants receiving the incorrect breast milk and outlining risk reduction strategies. In response, some facilities have turned to solutions such as a breast milk bar coding system to reduce errors.

"You have a refrigerator full bottles of milk that say 'Babyboy Johnson or Babyboy Jackson," Adelman says. "Now that it says 'Wendysboy' or 'Judysboy,' you can imagine a similar reduction will happen, even though we don't have the automated measure to detect it. We're making a presumption that it's preventing other types of errors as well."

According to a survey conducted through the American Academy of Pediatrics (AAP), 81.7% of NICUs reported using a non-distinct naming convention. Transitioning to a distinct naming convention would require widespread change throughout the industry; however, Adelman argues that it's a necessary change. In the study, the authors state that The Joint Commission "might consider prohibiting the use of non-distinct naming conventions" just as the accrediting agency once required hospitals to replace the abbreviation "QD" (once a day) with "DAILY" because of the frequent confusion with "QID" (four times per day).

Adelman adds that the change is undeniably simple.

There may be some work involved in adjusting admitting policies and procedures, and ensuring that the naming fits in with clinicians' workflows, but comparatively, it's an easy fix.

"I've done other projects where you have to change the computer system and that's an incredibly complicated system to set up, but changing the name is a very simple thing to do," he says. "You don't have to work with technology at all, you just have to work with admitting."

The reaction from clinicians at Montefiore, who know this problem existed, has been universally positive, he adds.

"It's one of those things where it's obvious once you think about it, so once we did it in Montefiore, it made a lot of sense."