Incorporating mothers’ names into newborns’ IDs led to a drop in patient mix-ups, say researchers
MONDAY, July 13, 2015 (HealthDay News) — Using more specific names for newborns may reduce hospital mix-ups by about a third, according to research published online July 13 in Pediatrics.
Jason Adelman, M.D., a public safety officer in the Montefiore Health System in New York City, and colleagues used a tool that looks for all hospital orders that are placed and retracted within 10 minutes, and then placed on another patient by the same clinician within the next 10 minutes. The researchers tracked these errors for one year at the two neonatal intensive care units (NICUs) of Montefiore Medical Center in Bronx, N.Y. During this time, the NICUs used the generic “Babygirl Jones” type of naming.
Subsequently, the hospital adopted the more specific “Catherinesgirl Jones” version. For twins and triplets, the new procedures used numbers at the start of the name, such as “1Sallysgirl Franklin” and “2Sallysgirl Franklin.” The researchers tracked the errors for another year, finding that errors dropped by 36.3 percent following the change. After accounting for clusters of orders within order sessions, the researchers calculated that the new naming reduced errors by a third (odds ratio, 0.64).
Adelman told HealthDay that a drawback to this study is researchers cannot track the errors that actually make it to the patient. “We can only rely on reporting, and the evidence shows that doctors only report 1 percent of the errors they make,” he said. Still, he hopes this study will prompt more hospitals to change their procedures. “Now that there’s strong evidence that this really makes a difference, I’m hoping this will accelerate the adoption of using these more distinct names,” he said.
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