By: Joann Schulte DO, MPH; Editorial Board Member
William Shakespeare was sure that a rose by another name would still smell as sweet. But the playwright's sentiment from Romeo and Juliet doesn't apply to patients. Matching up the medication and the name can be a matter of life or death. Numerous quality improvement projects have focused on patient safety and an article by Adelman et al. (doi: 10.1542/peds.2015-0007) published this month in Pediatrics explores what can happen in nurseries where neonates are often Baby Boy Jones or Baby Girl Garcia.
Oh the parents have plans to make their newborns into individuals with a first name that might be Stephen James or Esperanza Maria. Most of the 4 million infants born in 2012 needed no major interventions after birth and soon departed for home with their parents. But 12% of those infants were admitted to neonatal intensive care units (NICUs) for prolonged therapy that might be anything from jaundice to cyanotic heart disease. You can be sure that more than one NICU had multiple babies with the name Baby Girl Jones or Baby Boy Garcia. When multiple babies share the same or similar names, the chance for medical errors obviously goes up.
The study published this month in Pediatrics is important for several reasons. First the authors surveyed NICU physicians about naming conventions for neonates and then tested a hypothesis that assigning a unique name at birth would be associated with a decrease in wrong patient errors.
The authors did an email survey of the 3,179 members of the AAP section on Perinatal Pediatrics asking about naming convention and identified which of the 886 NICUs they practiced in. The authors got 453 responses, representing 339 NICUs for a 37.8% response rate. More than 80% of the NICUs (277, 81.7%) reported using non-distinct naming conventions of Baby Boy or Baby Girl.
The intervention was done at Montefiore Medical Center in the Bronx, N.Y. where patients are cared for in two NICUs, a Level IV with 35 beds and a Level III with 15 beds. The distinct naming convention implemented at Montefiore incorporated the mother's first name. So Baby Girl Jones became Martha's Girl Jones and Baby Boy Garcia became Lucia's Boy Garcia. The naming convention made the infants into more distinct individuals.
The authors examined wrong-patient error rates before and after implementation of the distinct naming intervention. They used the Retract and Reorder (RAR) tool, which identifies orders placed into the computer system and then retracted and entered for a different patient. Such events are considered near misses where the patient is not harmed because the error is caught in time. Earlier research has suggested that more than three-fourths of RAR events represent wrong patient errors. The use of such near misses to test patient safety improvements is encouraged by patient safety organizations.
During the pre-intervention period, Montefiore physicians placed 157,857 orders for 1,115 neonates. After the name change convention placed 142,437 orders for 1,067 neonates. The RAR error rate decreased from 59.5 per 100,000 orders to 37.9 per 100,000 orders, a decrease of 36.3%.
This study is important because it demonstrates that Baby Boy and Baby Girl naming conventions are a recipe for trouble. The simple intervention of attaching the mother's first name to her infant reduced errors and that's an important outcome. With apologies to Shakespeare, a baby with a unique name in a NICU will be safer and that is a good sniff for patient safety.