Identification System Reduces Neonatal ICU Errors

A unique naming system reduces confusion and miscommunication in the neonatal intensive care unit (nICU), according to a new study.

Developed by researchers at Montefiore Medical Center (New York, NY, USA), the naming system helps reduce near miss wrong-patient orders in the electronic medical record (EMR) by more clearly identifying neonates who have yet to be given a first name. The system involves a formula to create a first name for neonates by assigning a number first (i.e., 1, 2, 3, etc.), followed by the mother's first name, then the letter "s," and finally the gender, boy or girl. An example is 2MariasBoy.

A study to examine the effectiveness of the naming system found that for the period July 2013 to February 2014, only 33 errors were found among 98,513 individual EMR orders. This was compared to the old naming system (BabyBoy or BabyGirl) from November 2012 to June 2013, which resulted in 68 errors found among 101,731 individual orders. The implementation of the new naming system therefore resulted in a 49.9% reduction in the error rate for individual orders.

To further secure correct nICU identification, the researchers ran another study that introduced an identification re-entry function. The researchers found that the added entry reduced the magnitude of error in the nICU considerably, a reduction greater than that in the non-neonate hospitalized population. The studies were presented at the annual American Academy of Pediatrics (AAP) meeting, held during October 2014 in San Diego (CA, USA).

“We did a national survey of NICUs across the country. Over 300 NICUs responded, and more than 80% said they used BabyBoy/BabyGirl or BB/BG in their nICUs,” said lead author and study presenter Jason Adelman, MD, patient safety officer (PSO) at Montefiore Medical Center. “The issue is that when babies are born in a hospital, very often parents don't have the names ready to go the second the baby [is born], but we must put a wrist band on the child [immediately].”
EMRs typically generate sequential patient record numbers. As NICU babies are generally born within days, and even hours of one another, the numbers are often close.

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