Establishing a Naming Convention to Prevent Misidentification Errors

 

The Joint Commission (JC) has a relatively new element of performance that went into effect in January 2019. Its intention was to decrease the risk of misidentification errors in newborns.

It resides under the National Patient Safety Goal 01.01.01 which states, “Use at least two patient identifiers when providing care, treatment, and services.” When this goal was introduced some years ago, it was applied in the Neonatal Intensive Care Unit (NICU) along with all other areas of care. The difference is that newborns cannot speak for themselves or participate in their identification and care in any way. Names are often similar, medical record numbers may be very similar, and dates of birth perhaps the same or close.

Naming conventions matter

Errors have been reported associated with non-distinct naming conventions for newborns. The new JC element of performance states, “Use distinct methods of identification for newborn patients.”

All obstetric and newborn care providers are very conscious of the need for quick identification of the newborn before separating mother and baby to prevent mistakes in not pairing mothers with their own baby. A mistake we all want to avoid! Therefore, bands are created in the delivery room. These may contain only the mother’s information with an identification number printed on the band. Once the baby is admitted, whether in the newborn nursery/postpartum unit or NICU, another band is usually created that identifies the newborn in some unique way such as mother’s last name, sex and often mother’s first name. In many cases, a first name has not yet been assigned to the newborn so admitting the infant under their given name may not be possible at this time. Even if parents’ may know what name they have chosen, they may not have the opportunity to let the NICU team know. 

Milk mix-ups and patient misidentification error prevention

Gray, Suresh, et al (2006) reported on the risk of misidentification errors in the NICU. They reported a common misidentification error with the feeding of a mother’s expressed breast milk (EBM) to the wrong infant.3

It was reported in the Vermont Oxford Network (Suresh et al, 2004) that 25% of wrong patient errors involved EBM.4 Error sources were varied and included labeling errors and errors in verification.

Others also report breast milk errors at high rates with one report of 12 errors in 18 months.5 Gray, Suresh et al (2006) compared the frequency of feeding EBM in a 48-bed NICU, estimated to have occurred about 40,000 times per year.4

The process of matching EBM to the infant is similar to the process of matching blood to a recipient.  Even with safeguards in place, transfusions given to the wrong patient occurs about 1 out of 16,000 to 20,000 times per year. By comparison, EBM checks are often less rigorous than those associated with blood transfusions and it may be expected that more wrong breast milk errors would occur in a large, busy unit without additional human error safeguards. Non-distinct naming conventions only serve to increase the risk of these, as well as other errors.

Adelman, Aschner & Schechter published results of a survey around naming conventions. They received responses from 339 NICUs in the United States and found that all but one of the responding NICUs used a temporary naming convention – meaning that the given name was not used at admission.6 50 of the responding NICUs indicated names were changed during the hospitalization to include the infant’s own name. It is important to note that in the “non-distinct” naming convention reported by 82% of the responding NICUs, the mother’s last name and BabyBoy/BabyGirl, BB, BG with a single letter denoting multiple gestation babies was reported (for example, Smith, BB or Smith, BabyBoy). These 82% did not include the mother’s first name in the infant’s naming convention. 18% reported using a distinct naming convention that included the mother’s first name when creating an infant name such as Smith, BabyBoy Judy or Smith BG Judy. While this is the format I have seen in my multiple work settings for many years, errors have been reported in which medications or procedures ordered for the baby was delivered to the mother or vice versa.7

Another problem reported by some of these NICUs is that the name is truncated by the electronic medical record. This may cut off the multiple designation or sex of the baby, thus making it difficult to identify the infant by name at all. Only 50 of the responding sites indicated that names were changed during the hospitalization to the infant’s permanent, unique name. This can create confusion, since in some cases changing the medical record to the infant’s permanent name may change both first and last names. It would require the need to change ID bands and perhaps paper documents that are part of the medical record now showing a different name. This wasn’t addressed in this survey, but in my experience over the last five years, less than 30% of babies have their mother’s last name after discharge. The baby’s first name is often posted at the bedside as soon as it is known, but not on the electronic health record during the original hospital stay.

The Joint Commission recommendations

What is the recommendation from the JC?  They simply give examples of how misidentification can be avoided.  These include:

• Distinct naming systems could include using the mother’s first and last names and the newborn’s gender (for example: “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples)
• Standardized practices for identification banding such as two body-site identification and barcoding
• Establish communication tools among staff (for example visually alerting staff with signage noting newborns with similar names) 

Perhaps infants at the highest risk of identification errors are those with common names, which can vary by areas of the country.  The third example given by the JC recommends some method to alert staff when two infants are in the unit with the same last name. This is further complicated if mothers share both first and last name, which I have seen rarely but it does happen!  Some suggestions of how this might be accomplished is to put colored dots on name tags, notes on the bed itself that draw attention to this, and to make sure both babies are not physically near each other or in the same nursing assignment. 

Perhaps you recently received an invitation to complete a survey from the Institute of Safe Medication Practices (ISMP) about naming conventions used for newborns. If so, hopefully you completed the survey and submitted it.  This survey is in response to continued reports of misidentification errors even after the JC recommendations were implemented. The ISMP is making an effort to determine how/if NICUs have changed their naming conventions, if names are changed during the infant’s hospital stay, and the incidence of misidentification errors. Stay tuned for further recommendations on this. 

Meanwhile, hospitals should investigate ways to implement factors like barcoding to safeguard against human errors such as misreading a medical record number or name, and/or truncation of names in an electronic health record.

References:

1. The Joint Commission (2018). R3 report: Requirement, rationale, reference. Retrieved on September 26, 2019 from https://www.jointcommission.org/assets/1/18/R3_17_Newborn_identification_6_22_18_FINAL.pdf
2. The Joint Commission. Temporary names put newborns at risk. Quick Safety. 2015;no.17:1-2. Retrieved on September 26, 2019 from https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_17_Oct_2015_10_20_15.pdf
3. Gray JE, et al: Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 117(1); January 2006
4. Suresh G, Horbar JD, Plsek P, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics.  2004;113:1609–1618
5. Dougherty D, Giles V. From breast to baby: quality assurance for breast milk management. Neonatal Netw. 2000;19:21–25
6. Adelman JS, Aschner JL, Schechter CB, Angert RM, Weiss JM, Rai A, Parakkattu V, Goffman D, Applebaum JR, Racine AD, Southern WN. Babyboy/Babygirl: A National Survey on the Use of Temporary, Nondistinct Naming Conventions for Newborns in Neonatal Intensive Care Units. Clinical pediatrics. 2017 Oct;56(12):1157-9.
7. https://www.ismp.org/resources/whats-name-newborn-naming-conventions-and-wrong-patient-errors, Retrieved on September 24, 2019.