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 As a marker of potential mistakes, researchers analyzed how often
doctors order tests, procedures or drugs for one newborn baby and
then quickly retract it and place the same order for a different
newborn.
At Montefiore Health System in the Bronx, in two neonatal intensive
care units (NICUs), they compared this so-called “retract and
reorder” rate for one year before and after the hospital changed its
ID system for newborns.
In the old system, generic IDs showed only the infant’s gender and
last name, such as “babygirl Johnson.”
In the new system, launched in July 2013, the babies’ IDs also
incorporated the mother’s first name, such as “Wendysgirl Johnson.”
During the first year of the new IDs, the retract and reorder rate
was about 36 percent lower than it was during the last year under
the old system.
Doctors’ computer orders counted as retract and reorder entries if a
physician retracted a request within 10 minutes of making it and
then placed an identical order for a different patient.
“We call this an ‘oops’ measurement because these are near misses,
and the good news here is that the findings suggest hospitals can
decrease these errors by more than a third by switching to a new
naming system,” said lead study author Dr. Jason Adelman, patient
safety officer at Montefiore.
A previous study found that about 11 percent of medical errors in
NICUs are due to patient misidentification, Adelman and colleagues
report in the journal Pediatrics. Part of the problem is that many
newborns in the NICU have similar last names and birth dates, the
authors note.
Along with changing the system for singleton births, Montefiore also
switched IDs for multiples, incorporating not just the mother’s
first name but also a number. Twins, for example, might now have IDs
that say “1Judysboy” and “2Judysboy.”
During the study period, under the old naming system, there were
157,857 orders placed for 1,115 babies, while there were 142,337
orders for 1,067 infants under the new guidelines.
For every 100,000 orders, the overall retract and reorder rate fell
from 59.5 with the old IDs to 37.9 with the new ones, the study
found.
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The reduction was more pronounced for orders placed by doctors in
training, and for male babies.
One shortcoming of the study is that it didn’t have enough newborns
from multiple births to measure how much the new naming system might
reduce errors for twins or triplets, who may be at increased risk
for mistakes under older ID systems, the researchers acknowledge.
It’s also possible that because doctors knew about the new naming
system and the rationale behind it, they became more careful with
their orders as a result, the authors note.
Even so, this naming format has proved effective elsewhere, said Dr.
Amir Kushnir, head of neonatology and the NICU at Baruch Padeh
Medical Center, Poria Tiberias, Israel.
Israeli government hospitals all register babies in the format
“WendysGirl Smith,” Kushnir, who wasn’t involved in the study, said
by email.
“All patients in the hospital are at risk of misidentification, but
the risk of newborns being misidentified is stronger because
demographic details of those babies are very similar,” Kushnir said.
SOURCE: http://bit.ly/1MpJy2L Pediatrics, online July 13, 2015.
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