Effect of an Alternative Newborn Naming Strategy on Wrong-Patient Errors: A Quasi-Experimental StudyFunding This research was supported in part by a grant (No. R21HS025443) from the Agency for Healthcare Research and Quality (AHRQ). The content is sole responsibility of the authors and does not necessarily represent the official views of the AHRQ.
21 August 2019
29 January 2020
01 April 2020 (online)
Objectives Newborns are often assigned temporary names at birth. Temporary newborn names—often a combination of the mother's last name and the newborn's gender—are vulnerable to patient misidentification due to similarities with other newborns or between a mother and her newborn. We developed and implemented an alternative distinct naming strategy, and then compared its effectiveness on reducing the number of wrong-patient orders with the standard distinct naming strategy.
Methods This study was conducted over a 14-month period in the newborn nursery and neonatal intensive care units of three hospitals that were part of the same health care system. We used a quasi-experimental study design using interrupted time series analysis to compare the differences in wrong-patient orders (an indicator of patient misidentification) before and after the implementation of the alternative distinct naming strategy.
Results Overall, there were 25 wrong-patient errors per 10,000 orders during entire study period (36.8 per 10,000 before and 19.6 per 10,000 after). However, there was no statistically significant change in the rate of wrong-patient ordering errors after the transition from the distinct to the alternative distinct naming strategy (β = 0.832, 95% confidence interval [CI] = −0.83 to 2.49, p = 0.326). We also found that, overall, 1.7% of the clinicians contributed to 62% of the wrong-patient errors.
Conclusion Although we did not find statistically significant differences in wrong-patient errors, the alternative distinct naming approach provides pragmatic advantages over its predecessors. In addition, the localization of wrong-patient errors within a small set of clinicians highlights the potential for developing strategies for delivering training to clinicians.
E.P., M.L., J.A., and T.G.K. conceived the study. E.P. and T.G.K. conducted the data analysis; all authors reviewed the analysis and were involved in the writing of the manuscript.
Protection of Human and Animal Subjects
The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by Washington University Institutional Review Board.
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