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10.10.2017 Category: News

Research on preventing wrong-patient errors in the NICU

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The failure to correctly identify a patient in the hospital or other health-care environments can occur under multiple circumstances. Even tiny careless mistakes in patient identification can lead to wrong-patient errors and may cause inconvenience and significant harm to the patient. Infants in the Neonatal Intensive Care Unit (NICU) are at particularly high risk for wrong-patient errors. Researchers from New York and Ohio conducted a quality improvement study to learn more about the frequency and risk factors of wrong-patient-errors in the NICU and to assess the effectiveness of different interventions for preventing these errors.

Adelman et al. (2017) demonstrated that NICU patients have characteristics that increase the risk of wrong-patient errors, e.g. the use of non-distinct temporary first names for newborns, such as “Babygirl” or “Babyboy”, or nearly identical names and medical record numbers of twins, triplets, and higher-order multiples. Medical record numbers being assigned sequentially are another risk factor as this may result in infants having similar medical record numbers if they are born in close temporal proximity. 

With the aim of evaluating strategies for preventing misidentification, the researchers looked at the rates of wrong-patient electronic orders in NICU and, as comparator, non-NICU paediatric units between January 2007 and June 2015. They reviewed more than 850 000 NICU orders and more than 3.5 million non-NICU paediatric orders.

During the baseline period (January 1, 2007 through June 30, 2010), no intervention for preventing errors was used. Baseline results revealed that wrong-patient orders occurred more often in NICU than in non-NICU paediatric units. In the second period (January 1, 2012 through June 30, 2013), an ID re-entry intervention was implemented. In this intervention, access to the order entry system is blocked until the patient’s identity is verified by re-entering the baby’s initials, age, and sex. 

After the implementation of the ID re-entry intervention errors in the NICU dropped by almost 50%. In the third period (July 1, 2013 through June 30, 2015), a distinct naming intervention for newborns was implemented in addition to the re-entry system. Newborns were no longer given non-distinct temporary names, but rather temporary names that included the mother’s first name, the infant’s sex, the mother’s last name, and in case of multiple births a number (e.g. 1Wendysboy Adelman). This combination resulted in further error reduction by more than 10% in the NICU.

In summary, the results of the study showed a significantly higher frequency of wrong-patient orders (per 100 000 orders) in the NICU compared to non-NICU paediatric orders. The risk for wrong-patient errors could be tremendously reduced by the implementation of a combined ID re-entry intervention and a distinct naming intervention.

View more (Original study, Pediatrics)

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