·  Legal News, Analysis, & Commentary

Health & Medicine

NICU Identity Mistakes Cause “Wrong Patient Errors”

— July 17, 2015


Art imitates life. A baby is born and must be whisked away to the neonatal intensive care unit (NICU) due to serious complications or prematurity. These are time-sensitive situations and don’t allow for much parent/child contact including naming the baby, unless the parents already have a name chosen. Standard procedure is to give the infant a temporary name using its gender and the parents’ last name. This results in names such as Babygirl Johnson and Babyboy Gonzalez. However, this convention also leads to an astonishing number of NICU identity mistakes, from treatment planning up to and including sending the baby home with the wrong parents.

While this is a viable plot for any TV show or movie of the week, it also happens in real life. In fact, the American Academy of Pediatrics discovered, in a survey of 339 medical organizations, that 82% used that standard naming convention. The journal Pediatrics published a study this week. The study dealt with the rates of “wrong-patient errors” with the traditional naming convention compared to those with a newer convention. The new convention changes the “baby” part of the name to the mother’s first name. Thus, Babygirl Johnson becomes Annsgirl Johnson and Babyboy Gonzalez becomes Mariasboy Gonzalez.

Researcher wrote that “Replacing a non-distinct naming convention with one that uses distinct names is a simple and effective intervention that is not costly, labor intensive, or dependent on new technology and may be easily implemented in most NICUs.” How effective was this new convention?

The study showed that this simple change reduced the cases of NICU identity mistakes by up to 40%.

While not perfect, it’s certainly a step in the right direction, as Montefiore Medical Center found out. It started using the newer convention in July 2013. Researchers examined the pre-change rate of NICU identity mistake as compared to the post-change rate. Specifically, they tracked the number of treatment orders issued by doctors for particular patients that were then retracted only 10 minutes later.

Their findings were shocking. Up to 76% of retracted orders were due to NICU identity mistakes. These mistakes involved issues such as connecting imaging or pathology test results to the wrong baby and, most frighteningly, giving blood products to the wrong child.

The researchers wrote, “One particularly concerning wrong-patient error unique to NICUs and hospital nurseries is feeding a mother’s expressed breast milk to the wrong infant. “The use of distinct patient names printed on breast milk bottles may also decrease the risk of a nurse removing the wrong bottle from a nursery refrigerator.”


NICU Naming Conventions Cause Wrong-Patient Errors

Join the conversation!