Distinct NICU Newborn Naming Linked to Reduced Error

1. With the implementation of a distinct and unique naming system in neonatal intensive care units (NICU), potential wrong-patient errors were reduced by a total of 36.3%.
2. The greatest reductions in errors were seen among orders placed by house staff (interns, residents, and fellows) and in orders placed on male patients.

CC Flikr Chris Sternal-Johnson NICU

In 2012, approximately half a million infants were admitted to NICUs in the United States, and in order to prevent delay, some hospitals may assign newborns temporary, generic first names, such as Babygirl or Babyboy. Previous research has shown that 11% of medical errors in NICUs were attributable to patient misidentification errors, but no study has examined the possible association of temporary names with wrong-patient medical errors.

Authors of the current study sought to determine whether nondistinct names for newborns increase the frequency of wrong-patient errors and if unique first names could potentially decrease this problem.

After the establishment of a distinct naming convention, it was estimated that potential wrong-patient errors were drastically reduced. This reduction was seen in the majority of all patient and provider subgroups analyzed.

This study may be limited by the possible presence of the Hawthorne effect, inability to detect high-risk subgroups, and in that the error estimation tool used had not been specifically validated for use in the NICU. However, the results should encourage the adaptation of a more distinct and unique naming system in all NICUs in order to help reduce the occurrence of wrong-patient errors.


Source: 2 Minute Medicine