Use of Temporary Names for Newborns and Associated Risks

Adelman, Jason S.; Aschner, Judy L.; Schechter, Clyde B.; Angert, Robert; Weiss, Jeffrey M.; Rai, Amisha; Berger, Matthew; Reissman, Stan; Parakkattu, Vibin; Chacko, Bejoy; Racine, Andrew D.; Southern, William N.

doi:10.1542/peds.2015-0007

Cited by 37 publications

(49 citation statements)

References 12 publications

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“…The Health Department of the United Kingdom recommends that this record is unique and used by all health services, but privacy and safety issues, such as theft of personal information, and flaws in the combination of patients in these electronic systems indicate the need to resort to other identifiers. Clinical data, name, surname, date of birth, social security number, address, phone number, postal code and gender can be combined to allow the correct patient identification and prevent duplication of medical records or multiple recording of the same user, as has been demonstrated by several authors (18)(19)(20)(21)(22)(23) . Similar or identical names can originate mistakes when computed systems require identifiers -first and last names and numerical registries -to find patient information in health services (2,24) .…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the risk of misidentification of women in a public maternity hospital

2018

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Objective: To determine the frequency of similar names and hospital records of women in a public teaching maternity hospital and the risk of misidentification resulting from the similarity in spelling and pronunciation of the names and in records. Method: Quantitative, documental and case study of 5,975 admissions that occurred between 2011 and 2014. The data name, admission and discharge date, date of birth, hospital record and bed number were collected from an electronic information system. Analysis encompassed descriptive statistics and design of an algorithm for comparison of text and sound. Results: Examination of the names revealed that 86% of the misidentification cases resulted from identical surnames and 96.5% from a sound similarity in the first names. There were patients with identical first and last names at least one day a week. Conclusion: The risk of misidentification of patients is a reality, which stresses the importance of checking and pronouncing the complete names correctly.

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Section: Discussionmentioning

confidence: 99%

Evaluation of the risk of misidentification of women in a public maternity hospital

2018

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“…Further steps can be taken today as regard to existing processes and practices to address patient identification errors. Practices that can enhance patient matching rates include requiring patients' photos to be taken at registration and incorporating them into patients' medical records so that they are visible to all clinicians across the enterprise, adopting a standard for entering temporary names for newborns in accordance with the Joint Commission's elements of performance to enhance patient identification with infants, and implementing standard processes for how staff should record certain patient demographic data attributes including patients' names and addresses [39,58,59].…”

Section: Recommendation 3: Guidance On Preventing Adverse Events Relamentioning

confidence: 99%

Patient Identification Techniques – Approaches, Implications, and Findings

2020

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Objectives: To identify current patient identification techniques and approaches used worldwide in today’s healthcare environment. To identify challenges associated with improper patient identification. Methods: A literature review of relevant peer-reviewed and grey literature published from January 2015 to October 2019 was conducted to inform the paper. The focus was on: 1) patient identification techniques and 2) unintended consequences and ramifications of unresolved patient identification issues. Results: The literature review showed six common patient identification techniques implemented worldwide ranging from unique patient identifiers, algorithmic approaches, referential matching software, biometrics, radio frequency identification device (RFID) systems, and hybrid models. The review revealed three themes associated with unresolved patient identification: 1) treatment, care delivery, and patient safety errors, 2) cost and resource considerations, and 3) data sharing and interoperability challenges. Conclusions: Errors in patient identification have implications for patient care and safety, payment, as well as data sharing and interoperability. Different patient identification techniques ranging from unique patient identifiers and algorithms to hybrid models have been implemented worldwide. However, no current patient identification techniques have resulted in a 100% match rate. Optimizing algorithmic matching through data standardization and referential matching software should be studied further to identify opportunities to enhance patient identification techniques and approaches. Further efforts to improve patient identity management include adoption of patients’ photos at registration, naming conventions, and standardized processes for recording patients’ demographic data attributes.

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“…RAR has been successfully used to measure the rate of intercepted wrong-patient errors in various settings including emergency departments, 13,14 a children's hospital, 12 and the NICU setting. 4,5…”

Section: Outcomementioning

confidence: 99%

“…sequentially, identical surnames for multiple patients, and multiple births (e.g., twins or triplets) with nearly identical names and MRNs. [3][4][5]9 Strategies to prevent patient misidentification involve double checking of identifiers by clinicians such as MRN and date of birth. However, for newborns' with the same date of birth, sequentially assigned MRNs may be identical except for a single digit.…”

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confidence: 99%

“…The distinct naming strategy decreased wrong-patient errors by 36% as compared with the nondistinct naming approach. 5 To avoid patient misidentification errors, we developed and implemented an alternative distinct naming strategy within our institution's EHR. In this paper, we describe an exploratory study comparing the distinct naming strategy with the alternative distinct naming strategy to investigate its effects on patient misidentification (i.e., wrong-patient errors).…”

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confidence: 99%

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Effect of an Alternative Newborn Naming Strategy on Wrong-Patient Errors: A Quasi-Experimental Study

et al. 2020

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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.

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Use of Temporary Names for Newborns and Associated Risks

Cited by 37 publications

References 12 publications

Evaluation of the risk of misidentification of women in a public maternity hospital

Evaluation of the risk of misidentification of women in a public maternity hospital

Patient Identification Techniques – Approaches, Implications, and Findings

Effect of an Alternative Newborn Naming Strategy on Wrong-Patient Errors: A Quasi-Experimental Study

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