BACKGROUND: Because there can be no delay in providing identification wristbands to newborns, some hospitals assign newborns temporary first names such as Babyboy or Babygirl. These nondistinct naming conventions result in a large number of patients with similar identifiers in NICUs. To determine the level of risk associated with nondistinct naming conventions, we performed an intervention study to evaluate if assigning distinct first names at birth would result in a reduction in wrong-patient errors.
METHODS: We conducted a 2-year before/after implementation study to examine the effect of a distinct naming convention that incorporates the mother’s first name into the newborn’s first name (eg, Wendysgirl) on the incidence of wrong-patient errors. We used the Retract-and-Reorder (RAR) tool, an established, automated tool for detecting the outcome of wrong-patient electronic orders. The RAR tool 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.
RESULTS: The reduction in RAR events post- versus preintervention was 36.3%. After accounting for clusters of orders within order sessions, the odds ratio of an RAR event post- versus preintervention was 0.64 (95% confidence interval: 0.42–0.97).
CONCLUSIONS: The study results suggest that nondistinct naming conventions are associated with an increased risk of wrong-patient errors and that this risk can be mitigated by changing to a more distinct naming convention.
- CI —
- confidence interval
- CPOE —
- computerized provider order entry
- DISTINCT —
- Distinct Naming Convention Trial
- OR —
- odds ratio
- RAR —
- TPN —
- total parenteral nutrition
What’s Known on This Subject:
Because there can be no delay in providing newborns with identification wristbands, some hospitals assign newborns temporary first names such as Babyboy or Babygirl. These nondistinct naming conventions result in a large number of patients with similar identifiers in NICUs.
What This Study Adds:
We performed an intervention study to determine if assigning distinct first names at birth would result in a reduction in wrong-patient errors. We used the Retract-and-Reorder tool, an established, automated tool to detect the outcome measure of wrong-patient electronic orders.
In 2012 there were 4 million infants born in US hospitals, with ∼12% being admitted to NICUs.1,2 The Eunice Kennedy Shriver National Institute of Child Health and Human Development identified wrong-patient errors in NICUs as 1 of 5 domains of errors in neonatology that require further research.3 Because there can be no delay in registering newborns and giving them identification wristbands, some hospitals assign newborns temporary first names, such as Babyboy or Babygirl. One theory why NICUs are prone to wrong-patient errors is the use of these nondistinct first names; however, no studies have provided direct evidence to support this hypothesis, nor have any demonstrated if transitioning to a naming convention that better distinguishes neonates from one another would prevent wrong-patient errors.
A 2004 study by Suresh et al4 found that of the 1230 medical errors reported by 54 NICUs in the Vermont Oxford Network, 136 (11.1%) were categorized as patient misidentification errors. In a subsequent study, Gray et al5 found that just over half of the average daily census in the NICU had similar identifiers to each other. The researchers hypothesized that the high proportion of patients in the NICU with similar identifiers increased the risk of misidentification, but they did not measure wrong-patient errors.
The Distinct Naming Convention Trial (DISTINCT) aimed to test the hypothesis that temporary, nondistinct names for newborns such as Babyboy or Babygirl increase the frequency of wrong-patient errors and that using a unique first name at birth would be associated with a decrease in wrong-patient errors in the NICU.
Overview of the DISTINCT Study
The main hypothesis of the DISTINCT study is that nondistinct temporary first names (eg, Babygirl) do not convey the added discrimination typically provided by unique first names, increasing the risk of orders being place on the wrong-patient in an NICU. As shown in Fig 1, the DISTINCT study incorporated the mother’s first name into the newborn’s temporary first name (eg, Wendysgirl) to provide an added level of distinction normally rendered by a unique first name and then examined the wrong-patient error rates in the NICU before and after implementing this new naming convention.
The DISTINCT study was conducted at Montefiore Medical Center, an academic health system in Bronx, New York, affiliated with the Albert Einstein College of Medicine and which includes 3 general hospitals, 1 children’s hospital, and 2 NICUs (a level IV NICU with 35 beds and a level III NICU with 15 beds). Both NICUs use the same computerized provider order entry (CPOE) system. The level IV NICU is an academic environment staffed by residents, fellows, and attending neonatologists and is the regional perinatal center and referral hospital that provides care for the most complex and critically ill neonates. The level III NICU is staffed by attending neonatologists, nurse practitioners, and physician assistants, without house staff. The intervention study was approved by the institutional review board at the Albert Einstein College of Medicine.
On July 1, 2013, a new distinct naming convention that incorporates the mother’s first name was implemented for all children born at Montefiore Medical Center (Fig 2), replacing the previous nondistinct naming convention of Babyboy/Babygirl. The new distinct naming convention for newborn infants included the mother’s first name, followed by the letter “s”, and then the gender of the infant (eg, Wendysgirl). For multiple births, a number was added to the front of the first name (1, 2, etc) to distinguish siblings from each other (eg, 1Judysgirl, 2Judysgirl). Clerical staff in the hospitals’ admitting departments were trained to use the new naming convention when creating an account for a newborn. This study was performed within Montefiore’s GE Centricity CPOE system (GE Healthcare, Milwaukee, WI).
To measure wrong-patient errors, we used the Retract-and-Reorder (RAR) tool, a validated and reliable method for identifying wrong-patient errors.6 The RAR tool 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. Previous research suggested that 76.2% of RAR events represent wrong-patient errors.6
RAR events are near-miss errors, self-caught by the clinician before they reach the patient. The Eunice Kennedy Shriver National Institute of Child Health and Human Development defines near-miss errors as “those errors that do not result in patient harm due to chance or timely interventions.”7 The use of near-miss errors to test safety improvements in health care is encouraged by major patient safety organizations because near-miss errors have been shown by industrial safety experts to have the same causal pathway as errors that cause harm.8–12
To determine the duration of the study, we performed a sample size calculation. Assuming a baseline error rate of 60 RAR events per 100 000 orders,13 and assuming an estimated effect size that was based on previous wrong-patient error research,6 our study duration of 1 year of control data collection and 1 year of intervention data collection provided >90% power to detect a 40% reduction in the odds of an RAR event. The effect size (ie, 40% reduction in RAR events) that we used for this calculation is taken from the results of a randomized controlled trial that evaluated the efficacy of an improved patient identification system for preventing wrong-patient electronic orders.6 Data were analyzed by using Stata version 13.1IC (StataCorp, College Station, TX).
The RAR order rates in the study NICUs were measured for 1 year before (July 1, 2012 to June 30, 2013) and after (July 1, 2013 to June 30, 2014) the implementation of the distinct naming intervention. The RAR order rate is defined as the number of RAR events divided by the number of orders. All NICU orders during the control and intervention periods, including medications, blood tests, imaging, and general care orders, were entered by using the CPOE system and were included in the analysis. All order data and RAR events were extracted from Montefiore’s electronic medical records.
Because orders are clustered within order sessions in which a provider places multiple orders on a single patient, we used general estimating equations to estimate the odds ratio (OR) of an RAR event using the distinct naming convention versus the nondistinct naming convention with cluster-robust SEs. As an exploratory analysis to determine if the benefit of the distinct naming convention was similar across different types of providers and patients, we constructed separate generalized estimating equation models for patient subgroups (gender, ages, racial/ethnic categories, and insurance) and provider subgroups (attending physician, house staff, nurse practitioners, and physician assistants). Subgroups with <2000 orders per year in total were included as “other.” In addition, subgroups with no RAR events in either the intervention or control periods were excluded from the exploratory analysis.
Patient demographic characteristics, including gender, race/ethnicity, and insurance, as well as provider characteristics are shown in Table 1. During the preintervention period there were 157 857 total orders placed for 1115 neonates; during the postintervention period there were 142 437 orders placed for 1067 neonates. A breakdown of RAR events by patient type, provider type, and order type is provided in Table 2.
There was a large and significant reduction in RAR events after the adoption of the distinct naming convention. The RAR error rate decreased from 59.5 per 100 000 orders preintervention to 37.9 per 100 000 orders postintervention, a 36.3% reduction. The OR of an RAR event post- versus preintervention was 0.64 (95% confidence interval [CI]: 0.42–0.97).
The benefits of the distinct naming convention were seen in most subgroups examined (Fig 3). The distinct naming convention had a particularly strong effect in reducing RAR events in orders placed by house staff (OR: 0.48; 95% CI: 0.24–0.93) and in orders placed on male patients (OR: 0.39; 95% CI: 0.19–0.83). ORs were not calculable for respiratory therapists and “other” providers because the respiratory therapists had no RAR events postintervention and the “other” providers group had no RAR events pre- or postintervention.
The implementation of a distinct naming convention for neonates requiring NICU admission resulted in a 36.3% reduction in RAR events, demonstrating that nondistinct naming conventions are associated with an increased risk of wrong-patient errors and that this risk can be reduced significantly by changing to a distinct naming convention. Our results support the hypothesis that the simple intervention of changing from a nondistinct naming convention (eg, Babygirl) to a distinct naming convention (eg, Wendysgirl) can result in a meaningful reduction in wrong-patient errors in NICUs.
A national survey conducted through the American Academy of Pediatrics Section on Perinatal Pediatrics found that 81.7% of the 339 responding NICUs reported using a nondistinct naming convention such as Babyboy or Babygirl, demonstrating the wide use of these hazardous naming conventions.14 Changing to a more distinct naming convention has the potential to prevent wrong-patient errors in the large number of NICUs that use nondistinct naming conventions.
This study is consistent with previous work that suggests that neonates are at increased risk of errors. In a 2012 study by Levin et al,15 a case-control experiment was conducted in a children’s hospital to evaluate if certain patient characteristics are associated with an increased risk of wrong-patient errors. The researchers found the risk ratio for newborns to be 3.57 (95% CI: 1.93–6.59) relative to patients of other ages.
Although the intervention was designed to measure wrong-patient electronic orders, there are other types of misidentification errors in NICUs that may result from the use of nondistinct first names, such as reading imaging tests or pathology specimens for the wrong patient or administering blood products to the wrong patient.16–18 One particularly concerning wrong-patient error unique to NICUs and hospital nurseries is feeding a mother’s expressed breast milk to the wrong infant.19 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. Removing the hazard of similar names has the potential to reduce many types of wrong-patient errors in the NICU.
It is worth noting that the distinct naming convention was specifically designed for the NICU, as opposed to other nonspecific interventions developed for general patient populations that may be less effective in the NICU. For example, a 2012 study by Hyman et al20 showed that patient photographs embedded in a CPOE system is a promising strategy for reducing wrong-patient orders; however, the authors acknowledged the limitation of this intervention for newborns whose physical appearance contributes little to distinguish one infant from another. Additional strategies aimed at preventing wrong-patient orders include using electronic decision support to verify patient identification before placing orders or alerting providers when orders are not consistent with the diseases listed in the problem list.6,21,22 However, these interventions can be costly, dependent on the type of CPOE system, and their effectiveness may diminish over time due to alert fatigue.23 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.
To accelerate the adoption of distinct naming conventions, regulatory bodies such as the Joint Commission might consider prohibiting the use of nondistinct naming conventions such as Babyboy or Babygirl. In an analogous initiative, the Joint Commission required that QD (once daily), which was sometimes confused with QID (4 times per day), be replaced with DAILY to prevent errors.24,25 Replacing nondistinct names such as Babygirl with discrete names such as Wendysgirl is a similar type of intervention.
The DISTINCT study used an established, automated tool to capture the primary outcome of RAR events. The RAR tool was developed for studying the effect of interventions on wrong-patient electronic orders. In a validation study conducted in a hospital setting that included, but was not limited to, the NICU, the RAR tool was found to have a positive predictive value for wrong patient errors of 76.2%.6 The RAR tool, therefore, slightly over-identifies wrong-patient errors by including some false-positives. For example, a false-positive RAR event might occur during total parenteral nutrition (TPN) rounds in the NICU, when a provider cancels a TPN order for a reason other than a wrong-patient error and then writes a parenteral nutrition order for the next patient in need of TPN.
The benefits of the distinct naming convention were particularly pronounced in orders placed by house staff and in orders placed on male patients (Fig 3). A larger study that allows for precise subanalysis may determine if certain provider types and patients are more or less impacted by this intervention.
In NICUs with nondiscrete naming conventions, multiples may have an increased risk of wrong-patient errors as a result of the near identical names of siblings (eg, BabyboyA Smith and BabyboyB Smith). However, we were not able to test this hypothesis or evaluate the effectiveness of the DISTINCT intervention specifically in multiples for 2 reasons: (1) we were unable to differentiate unrelated singletons with the same last name from multiples in our preintervention data set and (2) we did not have sufficient power to detect differences between subgroups. Further research is needed to determine if multiples have higher wrong-patient error rates compared with singletons and to assess the effect of the DISTINCT intervention on preventing wrong-patient errors in this subgroup of patients.
An alternate approach for replacing nondistinct naming conventions is to change newborns’ temporary names to their given names as soon as they are available. We explored implementing this solution but were deterred by the technical obstacle of reconciling 2 different names for 1 patient in the middle of an admission. This solution warrants further exploration.
This study has several limitations. First, the intervention study used historical controls and a secular trend might confound the results. Second, it was not possible to blind the ordering providers to the naming convention change, and thus providers may have improved their behavior in response to their awareness of being observed (ie, the Hawthorne effect). A longer study is needed to assess if the Hawthorne effect confounded our results. Third, the positive predictive value of 76.2% for the RAR tool was determined by using patients from a hospital setting across multiple units and was not specific to the NICU. Additional research validating the RAR tool specifically in the NICU is warranted. Finally, the study was not powered for subanalyses to identify high-risk subgroups, nor to evaluate the effect of the DISTINCT intervention on any identified high-risk subgroups.
Our findings suggest that the use of nondistinct, temporary first names for newborns is hazardous and that replacing a nondistinct, temporary naming convention with one that is more distinct may significantly reduce wrong-patient errors in the NICU.
We thank the Montefiore NICU staff, Admitting Department staff, Health Information Management staff, and the Registration Committee for their support of this project, as well as the Health Services Research Affinity Group for their valuable feedback on the analysis and draft of the manuscript.
- Accepted May 4, 2015.
- Address correspondence to Jason Adelman, MD, MS, Patient Safety Officer, Montefiore Medical Center, 111 East 210th St, Bronx, NY 10467. E-mail:
Drs Adelman, Racine, Angert, Southern, Aschner, and Weiss, together with Ms Rai and Mr Parakkattu, collaborated on conceptualizing, designing, and implementing the intervention study and reviewed and revised the manuscript; Dr Berger, Mr Reissman, and Mr Chacko designed the data collection tool, coordinated and supervised the data collection for the intervention study, and reviewed and revised the manuscript; Dr Schechter assisted Dr Southern in the analyses of the intervention study and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by institutional funds from Montefiore Medical Center.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- ↵Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Mathews TJ. Births: final data for 2012. Natl Vital Stat Rep. 2013;62(9):2–3
- US Department of Health and Human Services; Health Resources and Services Administration; Maternal and Child Health Bureau
- Suresh G,
- Horbar JD,
- Plsek P,
- et al
- Adelman JS,
- Kalkut GE,
- Schechter CB,
- et al
- ↵Raju T. NIH funding opportunity: patient safety research during neonatal care (2011). Available at: http://grants.nih.gov/grants/guide/pa-files/PAR-11-225.html. Accessed December 1 2014
- ↵Agency for Healthcare Research and Quality. Doing what counts for patient safety: federal actions to reduce medical errors and their impact—report of the Quality Interagency Coordination Task Force (QuIC) to the president. February 2000. Available at: http://archive.ahrq.gov/quic/Report/errors6.pdf. Accessed December 28, 2014
- Leape L, Abookire S. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems: From Information to Action. Geneva, Switzerland: World Health Organization; 2005. Available at: www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf. Accessed December 28, 2014
- Institute for Healthcare Improvement. Create a reporting system. April 2011. Available at: www.ihi.org/knowledge/Pages/Changes/CreateaReportingSystem.aspx. Accessed December 28, 2014
- Institute of Medicine
- Van der Schaaf T
- ↵Adelman JS, Southern W, Schechter C, et al. Reducing wrong-patient errors in the NICU through an electronic medical record identification re-entry function. Presented at: American Academy of Pediatrics National Conference and Exhibition; October 2014; San Diego, CA. Available at: https://aap.confex.com/aap/2014/webprogrampress/Paper26569.html. Accessed March 16, 2015
- ↵Adelman JS, Schechter C, Aschner J, et al. The “babyboy/babygirl” problem: evaluating the risk of non-distinct, temporary first names for newborns and measuring the effect of changing the paradigm to reduce wrong patient orders. Presented at: Vermont Oxford Network Conference; November 2014; Chicago, IL. Available at:www.vtoxford.org/meetings/AMQC/Handouts2014/LearningFair/Montefiore_BabyBoyBabyGirlIntheNICU.pdf. Accessed March 16, 2015
- ↵Levin HI, Levin JE, Docimo SG. “I meant that med for Baylee not Bailey!”: a mixed method study to identify incidence and risk factors for CPOE patient misidentification. AMIA Annu Symp Proc. 2012;1294–1301. Available at: www.ncbi.nlm.nih.gov/pubmed/23304408. Accessed March 16, 2015
- ↵Nuttall GA, Abenstein JP, Stubbs J, et al. Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors. Mayo Clin Proc. 2013;88(4):354–359
- Green RA,
- Hripcsak G,
- Salmasian H,
- et al
- ↵Ash JS, Sittig DF, Campbell E, Guappone K, Dykstra R. An unintended consequence of CPOE implementation: shifts in power, control, and autonomy. AMIA Annu Symp Proc. 2006;11–15. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1839304. Accessed March 16, 2015
- ↵The Joint Commission. Sentinel event alert: medication errors related to potentially dangerous abbreviations. 2001. Available at: www.jointcommission.org/assets/1/18/SEA_23.pdf. Accessed July 23, 2014
- ↵The Joint Commission. Facts about the official “Do Not Use” list of abbreviations. 2014. Available at: www.jointcommission.org/facts_about_the_official_/. Accessed July 23, 2014
- Copyright © 2015 by the American Academy of Pediatrics