Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU
BACKGROUND: NICU patients have characteristics believed to increase their risk for wrong-patient errors; however, little is known about the frequency of wrong-patient errors in the NICU or about effective interventions for preventing these errors. We conducted a quality improvement study to evaluate the frequency of wrong-patient orders in the NICU and to assess the effectiveness of an ID reentry intervention and a distinct naming convention (eg, “Wendysgirl”) for reducing these errors, using non-NICU pediatric units as a comparator.
METHODS: Using a validated measure, we examined the rate of wrong-patient orders in NICU and non-NICU pediatric units during 3 periods: baseline (before implementing interventions), ID reentry intervention (reentry of patient identifiers before placing orders), and combined intervention (addition of a distinct naming convention for newborns).
RESULTS: We reviewed >850 000 NICU orders and >3.5 million non-NICU pediatric orders during the 7-year study period. At baseline, wrong-patient orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs 74.9 per 100 000 orders, respectively; odds ratio 1.56; 95% confidence interval, 1.34–1.82). The ID reentry intervention reduced the frequency of errors in the NICU to 60.2 per 100 000 (48.7% reduction; P < .001). The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100 000 (61.1% reduction from baseline; P < .001).
CONCLUSIONS: The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units. Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.
- CHAM —
- Children’s Hospital at Montefiore
- CPOE —
- Computerized Provider Order Entry
- health IT —
- health information technology
- RAR —
With >800 NICUs in the United States caring for >350 000 of our most vulnerable patients, NICU patient safety is a national priority.1–3 Several studies have suggested that unique characteristics of neonates increase the risk of wrong-patient errors in the NICU and that infants from multiple births may be at particularly high risk. These risks include the following: the use of nondistinct, temporary first names for newborns (eg, “Babyboy” or “Babygirl”); medical record numbers being assigned sequentially, resulting in infants born in close temporal proximity having similar medical record numbers; and the large population of twins, triplets, and higher-order multiples in NICUs with nearly identical names and medical record numbers.4–6 Despite these apparent risks, it remains unknown whether the frequency of wrong-patient errors is higher in the NICU than in non-NICU pediatric units.
Previous research demonstrated that an ID reentry intervention, which requires users to actively reenter patient identifiers before placing orders, is an effective strategy for reducing wrong-patient orders in the hospital.7 This study included pediatric patients. A subsequent study demonstrated the effectiveness of replacing the standard nondistinct naming convention for newborns (eg, “Babygirl”) with a distinct naming convention that incorporates the mother’s first name (eg, “Wendysgirl”) for reducing wrong-patient orders in the NICU.4 However, there has been no evaluation of the effectiveness of the ID reentry intervention specifically in the high-risk setting of the NICU, nor has there been an evaluation of the effectiveness of combining an ID reentry intervention and a distinct naming convention in the NICU.
We conducted a quality improvement study to evaluate the baseline frequency of wrong-patient electronic orders in the NICU and to assess the effectiveness of an ID reentry intervention alone and in conjunction with a distinct naming convention for preventing wrong-patient orders in the NICU, using non-NICU pediatric units as a comparator. We used a validated, automated measure of wrong-patient orders to quantify the frequencies of these errors in the NICU and in non-NICU pediatric units, before and after implementation of the interventions.7
We hypothesized that the baseline frequency of wrong-patient orders is higher in the NICU than in non-NICU pediatric units, that verifying patient identification before placing orders is an effective approach for preventing wrong-patient orders in the NICU, and that the effectiveness of this ID reentry intervention is increased by the addition of a distinct naming convention. We tested our hypotheses with an observational study comparing wrong-patient order frequencies in the NICU with wrong-patient order frequencies in non-NICU pediatric units, and with serial before–after intervention studies.
We aimed to determine whether neonates in the NICU are at greater risk for wrong-patient orders than patients in non-NICU pediatric units and to determine whether an ID reentry intervention designed to reduce these errors in the entire hospital was effective in the NICU, both alone and in combination with the use of a distinct naming convention for newborns. To do this, we examined the frequency of near-miss wrong-patient orders in the NICU and in non-NICU pediatric units before and after an ID reentry intervention was implemented and again after a change from a nondistinct to a distinct naming convention for newborns with the ID reentry intervention still in place.
We defined non-NICU pediatric units as all general pediatric units, pediatric subspecialty units, and PICUs. These units were chosen as a comparator for the NICU because all patients admitted to these units have distinct names. Patients admitted to the general nursery were excluded.
This quality improvement study was conducted at the Children’s Hospital at Montefiore (CHAM), an academic pediatric hospital that is part of the Montefiore Health System in the Bronx, New York and is affiliated with the Albert Einstein College of Medicine. CHAM has 132 pediatric beds exclusive of NICU beds and provides an extensive range of subspecialty medical services for children. In addition, CHAM has 2 NICUs that are co-located with Montefiore’s labor-and-delivery units (level IV NICU with 35 beds, level III NICU with 15 beds).
This study was approved by the institutional review board at the Albert Einstein College of Medicine.
Primary Outcome Measure
We used the Wrong-Patient Retract-and-Reorder (RAR) tool to measure wrong-patient electronic orders. The RAR tool is a validated and reliable measure used for identifying wrong-patient orders that is endorsed by the National Quality Forum.8 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 demonstrated that 76% of RAR events represent true wrong-patient orders.7
RAR events are near-miss errors, self-caught by ordering providers before they reach the patient. The use of near-miss errors to test safety improvements in health care is encouraged by major patient safety organizations including the Institute of Medicine, Agency for Healthcare Research and Quality, World Health Organization, Institute for Healthcare Improvement, and the Joint Commission because they have been shown by safety experts to share the same causal pathway as errors that cause harm.9–13
ID Reentry Intervention
The ID reentry intervention is a health information technology (health IT)–based intervention that blocks access to the order entry screen until the provider verifies the patient’s identity by reentering the patient’s initials, age, and sex. Users were required to enter the age in number of days for newborns until 3 months old, then in months until 2 years old, and then in years for all patients ≥2 years old. This intervention was used for all patients admitted to Montefiore Medical Center and was built into Montefiore’s GE Centricity Computerized Provider Order Entry (CPOE) system (GE Healthcare, Wauwatosa, WI).
Distinct Naming Convention Intervention
Eighteen months after implementation of the ID reentry intervention, a distinct naming convention for newborns was implemented that replaced the previous nondistinct naming convention of “Babyboy” or “Babygirl.”4 The distinct naming convention included the mother’s first name, followed by the letter “s,” then the sex of the infant, and the mother’s last name (eg, “Wendysboy Adelman”). For multiple births, a number was added to the beginning of the first name to distinguish siblings from each other (eg, “1Wendysboy,” “2Wendysboy”). Registration staff in the hospital’s admitting departments were trained to use the new naming convention when creating an account for a newborn. The distinct naming convention applied only to newborns and had no bearing on non-NICU pediatric patients, whose given names were used.
Data were collected from NICU and non-NICU pediatric units from 3 time periods: baseline period (before the implementation of any intervention from January 1, 2007 through June 30, 2010), ID reentry intervention period (ID reentry intervention implemented on all units from January 1, 2012 through June 30, 2013), and combined intervention period (implementation of a distinct naming convention as an additional intervention for newborns from July 1, 2013 through June 30, 2015).
The 18-month period from July 1, 2010 through December 31, 2011 was the development and testing period, which was excluded from the analysis. During this period, we launched a quality improvement initiative to reduce wrong-patient orders by developing 2 health IT interventions implemented in the CPOE system. To test the effectiveness of these interventions for preventing wrong-patient orders, we conducted a 3-arm randomized controlled trial from December 17, 2010 to June 16, 2011.7 In 1 arm, we used the ID reentry intervention (as described), which required reentering the patient’s initials, age, and sex. In the second intervention arm, an ID verify alert displayed the patient’s name, age, and sex on the order screen, and providers could proceed only after clicking to verify the patient’s identity. Both health IT interventions significantly reduced the odds of a wrong-patient order compared with no intervention,7 but the ID reentry intervention was superior and was subsequently implemented for all inpatients. The second intervention, the ID verify alert, was discontinued.
No other interventions aimed at reducing wrong-patient errors were implemented during the entire 7-year study period. The data collection time line is presented graphically in Fig 1.
Because providers commonly place >1 order at a time on a single patient, orders are clustered within order sessions. An order session is defined as a series of orders placed by a provider on a single patient that begins with opening that patient’s order file and terminates when an order is placed on another patient or after 60 minutes, whichever comes first. We collected all orders, order sessions, and RAR events for each time period. In addition, we collected patient demographic data, including whether newborns were part of a multiple birth.
First, we examined the frequency of RAR events in the NICU and in non-NICU pediatric units during the baseline period, before the implementation of any interventions. We then examined, for the same time period, the frequency of RAR events in patients who represented multiple births (ie, twins, triplets, and higher-order multiples). Next, to determine the effect of the ID reentry intervention, we compared the frequency of RAR events in the NICU and in non-NICU pediatric units before and after the intervention was implemented. To account for a possible temporal trend that might confound the analysis, we used a difference-in-differences approach to compare the effect of the intervention in the NICU and non-NICU pediatric units, and we used the Wald test of an interaction term to test significance. We performed a similar analysis to determine the effect of the combined ID reentry and distinct naming interventions in the NICU compared with the ID reentry intervention alone in non-NICU pediatric units. Finally, we repeated the serial before–after analysis of RAR events in the subsets of NICU patients who represent singleton versus multiple births. To account for clustering of orders within order sessions, we used generalized linear models for all analyses, with order session number used to identify clusters.
The 3.5 years of baseline data, 1.5 years of ID reentry intervention data, and 2 years of combined ID reentry and distinct naming intervention data provided >90% power to detect a 25% reduction in the odds of an RAR event for each of the comparisons of interest. Data were analyzed via Stata version 13.1/IC (Stata Corp, College Station, TX).
We reviewed 850 790 NICU orders and 3 718 513 non-NICU pediatric orders during the study. The demographics of the patients who received the orders are provided in Table 1.
Baseline Error Frequency: NICU Versus Non-NICU Pediatric Units
During the 3.5-year baseline period, the RAR frequency in the NICU (117.2 RAR events per 100 000 orders) was significantly greater than that of non-NICU pediatric units (74.9 RAR events per 100 000 orders; odds ratio 1.56; 95% confidence interval, 1.34–1.82; P < .001). The risk of an RAR event was even higher among multiples in the NICU compared with patients in non-NICU pediatric units (138.1 RAR events per 100 000 orders versus 74.9 RAR events per 100 000 orders, respectively; odds ratio 1.84; 95% confidence interval, 1.41–2.42; P < .001).
Effect of the ID Reentry Intervention
Implementation of the ID reentry intervention was associated with a large and significant reduction in RAR events in both the NICU and non-NICU pediatric units (Table 2). The RAR error frequency in the NICU decreased from 117.2 per 100 000 orders before intervention to 60.2 per 100 000 orders after intervention, a 48.7% relative reduction in wrong-patient orders (P < .001). The RAR error frequency in non-NICU pediatric units decreased from 74.9 per 100 000 orders to 49.4 per 100 000 orders, a 34.1% relative reduction in wrong-patient orders (P < .001).
Effect of Combined Interventions
The addition of the distinct naming intervention for newborns was associated with a decrease of the RAR frequency in the NICU to 45.6 per 100 000 orders, which represents a 61.1% relative reduction in wrong-patient orders compared with baseline (P < .001). As a result of adding the distinct naming convention for newborns, the reduction of wrong-patient orders associated with the combined interventions in the NICU was significantly greater than the overall reduction of wrong-patient orders in non-NICU pediatric units (61.1% vs 28.4% relative reduction from baseline; P < .001 for interaction). The overall effect of the interventions in the NICU and in non-NICU pediatric units is shown graphically in Fig 2.
Effect of Interventions on Multiples
The reduction in wrong-patient orders with the ID reentry intervention in the NICU was similar for singletons (112.4 vs 57.7 per 100 000 orders; 48.6% relative reduction; P < .001) and multiples (138.1 vs 74.5 per 100 000 orders; 46.1% relative reduction; P = .055) compared with baseline. However, the added benefit of the distinct naming convention was observed only for singletons (Table 3).
We found that before either intervention, patients in the NICU were at significantly higher risk for a wrong-patient order compared with patients in non-NICU pediatric units, with the risk being even higher for multiples. The implementation of the ID reentry intervention and the addition of the distinct naming intervention for newborns were associated with a large combined total reduction of wrong-patient orders (61.1%) in the NICU compared with baseline. The combined effect of the 2 interventions moved the overall rate of wrong-patient orders in the NICU from significantly higher than non-NICU pediatric units to lower than non-NICU pediatric units. Taken together, these findings suggest that newborns in the NICU are at particularly high risk for wrong-patient orders but that this risk can be dramatically reduced with a combination of safety interventions.
It is interesting to note that whereas the ID reentry intervention had a strong and similar benefit for both singletons and multiple births, the addition of the distinct naming convention added benefit only for singleton births. This finding suggests an important weakness of the distinct naming convention: siblings continue to have similar identifiers to each other (eg, “1Wendysgirl Jones” and “2Wendysgirl Jones”). An improved naming convention is needed that specifically addresses the increased risk experienced by siblings of multiple births in the NICU.
Although the ID reentry intervention significantly reduced the frequency of wrong-patient orders both in the NICU and in non-NICU pediatric units, the magnitude of effect was greater in the NICU. This difference may be explained by the hazard of using nondistinct first names (eg, “Babyboy”) in the NICU, which resulted in a greater opportunity for improvement as compared with non-NICU pediatric units, where children possess distinct identifiers and characteristics that differentiate them. Because the distinct naming convention is relevant only for newborns, other approaches may be considered for reducing errors among older children. For example, in a study conducted by Hyman et al,14 displaying patient photographs in a CPOE system at a children’s hospital substantially reduced self-reported wrong-patient orders.
Previous work suggests that patients in the NICU are at high risk for wrong-patient errors. In a 2006 study by Gray et al,5 the risk of wrong-patient errors among NICU patients was estimated as the frequency of neonates sharing a similar name or medical record number with another patient on the unit. This study concluded that >50% of the average daily census of the NICU had similar patient identifiers and were at risk for a wrong-patient error. A 2002 study by Eisenfeld et al15 found that 61% of providers interviewed in the NICU did not know their patient’s first name, sex, or both. Although results of these studies suggest a high risk for wrong-patient errors in the NICU, we were able to confirm and quantify this risk with our findings that the odds of a wrong-patient order in the NICU are 56% greater than in non-NICU pediatric units.
Misidentification events in the NICU are not limited to wrong-patient orders. A 2016 study from the Pennsylvania Patient Safety Authority found an average of 2 newborn misidentification events reported by Pennsylvania hospitals each day, or 1 event for every 217 live births.16 A wide range of misidentification error types occurred, including administering medications and breast milk to the wrong infant, performing imaging studies and procedures on the wrong infant, and drawing blood from the wrong infant. In addition, in 2015 the Joint Commission reported 10 cases of surgeries performed on the wrong newborn because of similar identifiers.17 Using distinct temporary names (eg, “Wendysboy”) on wristbands, radiographs, blood tubes, and other health care labels will probably reduce a broad range of misidentification events in addition to the wrong-patient order errors we were able to measure in this study by using the RAR tool.
This study has several limitations. First, we used a measure of wrong-patient errors (the RAR tool) that captures near-miss errors but does not measure errors that reach the patient and cause harm. However, research has demonstrated that near-miss errors and errors that cause harm share the same causal pathway, suggesting that interventions that prevent near-miss errors will also prevent errors that reach the patient and cause harm.9–13 Second, the RAR tool measures wrong-patient orders but does not capture all types of wrong-patient errors that may occur. As a result, the effect of the distinct naming convention may be underestimated; use of distinct names in the NICU probably reduces other types of errors, such as feeding breast milk to the wrong infant. Finally, our study used an observational before–after design with a historical baseline; therefore, secular trends may have affected our results. To address this limitation, we used non-NICU pediatric units as a concurrent control and used a difference-in-differences analytic approach. In addition, we are confident that no other interventions aimed at reducing wrong-patient errors were implemented during the study period.
We demonstrated that before interventions aimed at preventing wrong-patient errors were implemented, the wrong-patient order rate in the NICU was significantly higher than that of non-NICU pediatric units and that the combined ID reentry intervention and distinct naming convention can significantly and dramatically reduce these errors in the NICU. Furthermore, our results suggest that similarities in names and medical record numbers of siblings of multiple births increase their risk of wrong-patient errors. More research is needed to explore improved naming conventions that will better distinguish multiples from each other.
- Accepted January 12, 2017.
- Address correspondence to Jason S. Adelman, MD, MS, Columbia University Medical Center/NewYork-Presbyterian Hospital, Milstein Hospital, 9 Garden South Room 328, 177 Fort Washington Ave, New York, NY 10032. E-mail:
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.
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- Copyright © 2017 by the American Academy of Pediatrics