New naming system for NICU babies can reduce medical errors, study shows

The naming system for newborns in neonatal intensive care units usually identifies babies by gender and last name, like Babygirl Jones. However, this naming system can lead to confusion and possibly wrong-patient errors, according to a study in Pediatrics.

Researchers at Montefiore Health System and the Children's Hospital at Montefiore in the Bronx, N.Y., conducted a study comparing wrong-patient error rates under the most common naming system, using gender and last name, and under a new system, where babies are named using the mother's first name, the baby's gender and last name, such as Wendysboy Jackson or Sheliasgirl Jones.

They used the Retract-and-Reorder tool to compare wrong-patient error rates. The RAR tool identifies orders placed on a patient, then retracted and placed by the same clinician on a different patient in the next 10 minutes. About 76 percent of those events represent wrong-patient errors.

They found that the new, more distinct naming system reduced RAR events by 36 percent compared with the prior system.

"Each day, healthcare providers in the NICU write dozens of orders for medications, laboratory tests and therapies for infants whose first name is 'babyboy' or 'babygirl," said Judy Aschner, MD, physician-in-chief at CHAM and as study coauthor. "This simple and highly effective approach to correctly identify a vulnerable newborn is an important step to ensure that each baby gets the appropriate care intended for their individual needs that helps them on the road to good health."

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