Jason Adelman1, Judy Aschner2, Clyde Schechter3, Robert Angert2, Jeffrey Weiss4, Amisha Rai5, Matthew Berger4, Stan Reissman5, Vibin Parakkattu6, Bejoy Chacko5, Andrew Racine2, William Southern4. 1. Albert Einstein College of Medicine, Bronx, New York; Montefiore Medical Center, Bronx, New York; jadelman@montefiore.org. 2. Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York; 3. Albert Einstein College of Medicine, Bronx, New York; Department of Family Medicine, Albert Einstein College of Medicine, Bronx, New York; and. 4. Albert Einstein College of Medicine, Bronx, New York; Montefiore Medical Center, Bronx, New York; 5. Montefiore Medical Center, Bronx, New York; 6. Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan.
Abstract
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.
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.
Authors: Eric S Hall; James M Greenberg; Louis J Muglia; Parth Divekar; Janet Zahner; Jay Gholap; Matt Leonard; Keith Marsolo Journal: Matern Child Health J Date: 2018-04
Authors: Chelsea T Redman; Pooja Reddy; Jerard Z Kneifati-Hayek; Jo R Applebaum; Wilhelmina Manzano; Dena Goffman; Jason S Adelman Journal: Pediatr Qual Saf Date: 2020-10-23
Authors: Hojjat Salmasian; Bonnie B Blanchfield; Kelley Joyce; Kaila Centeio; Gordon B Schiff; Adam Wright; Christopher W Baugh; Jeremiah D Schuur; David W Bates; Jason S Adelman; Adam B Landman Journal: JAMA Netw Open Date: 2020-11-02