What’s in a Name? Newborn Naming Conventions and Wrong-Patient Errors
According to the Centers for Disease Control and Prevention (CDC), nearly 4 million infants are born in the US each year, including approximately 132,000 multiple births.1 Unique characteristics of this newborn population pose significant challenges regarding accurate patient identification, which has led to wrong-patient errors.2-7 Unlike most older children and adults, newborns cannot speak and thus cannot participate in the patient identification process.2-4 Also, it is often difficult to distinguish one infant from another based on physical appearance or sex.5-7 Furthermore, hospitalized newborns may not have a given first name immediately after birth and often have similar last names, medical record numbers, and birthdates that can lead to errors caused by patient misidentification.
Newborns at Risk of Wrong-Patient Errors
During childbirth, one patient, the mother, becomes two or more patients, the mother and her newborn infant(s).2 Because newborn identification is a priority immediately after birth, hospitals and birthing centers typically utilize a newborn naming convention that assigns a temporary, nondistinct first name, such as Babyboy/Babygirl, Boy/Girl, or BB/BG, plus the mother’s surname to identify newborns, as parents may not have decided on the newborn’s first name for various reasons.4-7 These temporary, nondistinct names do not convey the added discrimination typically provided by unique first names. This results in many patients with similar identifiers, including mothers and their infants with the same last names, and many infants with the same nondistinct first names. In communities where there are a lot of commonalities among surnames, unrelated newborns could also have the same last name and nondistinct first name if they are the same sex (e.g., two unrelated babies identified as Smith, Babygirl).
Newborns in neonatal intensive care units (NICUs) and multiple birth siblings are particularly at risk for misidentification. In a NICU, newborns tend to receive more medications and treatments than healthy newborns,2,3 and 1 in every 4 serious medication errors in this setting is caused by misidentification.5,8 Twins and other multiples are at risk because they could have the same birthdate, sex, and last name.5 In addition to having the same nondistinct first and last name, multiples are often assigned a letter or number distinguisher (e.g., BabygirlA/BabygirlB) that may easily be overlooked. Furthermore, multiples often have a sequential medical record number differentiated by only one digit from a sibling since most are created in numerical order based on time of admission/birth.7 In one study, more than half of the average daily census of a NICU was at risk for wrong-patient errors as a result of similar names or medical record numbers.9 Multiple birth siblings accounted for more than half of this risk (although more than a quarter of singletons were at risk too). Given the increased possibility of premature birth and low birth weight, multiples make up more than 10% of the population in a NICU.5
Two other unique conditions with the newborn patient population increase the risk of errors caused by misidentification. First, the newborn’s electronic health record (EHR) must be changed from a temporary name to a permanent given name prior to or upon discharge when preparing official documentation for a birth certificate.4-7 This transfer process is unique to newborns and fraught with the risk of errors. Lastly, long temporary newborn names can become truncated in the EHR,5 on name bracelets, and on medication administration records (MARs), potentially removing the unique identifier for multiples or leading to misidentification between a mother and newborn. In a 2017 survey, nearly 20% of participants reported problems with insufficient character space for newborn names, particularly with hyphenated names or with multiples, and thus reported that names had dropped off patient records or name bracelets.5
Wrong-Patient Error Types
These unique conditions with the newborn patient population have been a major contributing factor to a wide range of reported wrong-patient errors, including medication errors; misfeedings of breastmilk; wrong person surgery, procedures, and diagnostic tests; order entry and documentation errors; misidentification of diagnostic results; and infants switched at birth and discharged to the wrong parents. For example, in 2015, The Joint Commission (TJC) reported 10 cases of circumcision performed on the wrong newborn.6 A 2016 study from the Pennsylvania Patient Safety Authority found an average of 2 newborn misidentification events reported by Pennsylvania hospitals each day, or 1 event for every 217 live births.2 The top two misidentification events were related to wrong procedures/tests and medication errors. Most of the mix-ups occurred between newborns with similar names.
The Joint Commission (TJC) National Patient Safety Goal (NPSG)
In 2015, TJC published a Quick Safety advisory about the risk of wrong-patient errors when using temporary, nondistinct newborn names.6 In the advisory, TJC offered several recommendations, including using a more distinct temporary newborn naming convention, and switching to the child’s given name as soon as it has been decided by the parents. After extensive research and a public comment period, TJC then added a new Element of Performance (EP 3) in 2018 to an existing National Patient Safety Goal (NPSG.01.01.01) associated with using at least 2 patient identifiers when providing care, treatment, and services.10 The new EP requires healthcare facilities to use distinct methods of identification for newborn patients. Examples provided to prevent misidentification include: using the mother’s first and last names and the baby’s sex (e.g., “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples) when naming newborns; standardizing practices for two body-site (wrist and ankle) identification banding and barcoding; and visually alerting staff with signage noting newborns with similar names.
While a 2015 study by Adelman et al. showed a significant reduction in wrong-patient errors when using a more distinct newborn naming convention,4 this study used a naming convention that incorporated the mother’s first name and the baby’s sex in a different way than recommended by TJC, which may be noteworthy. Instead of “Smith, Judy Girl” (or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples), as suggested by TJC, the study found a significant reduction in errors when using “Judysgirl Smith” (or “1Judysgirl Smith” and “2Judysgirl Smith” for multiples). Since the NPSG clearly references the Adelman et al. study, it is uncertain why the TJC example is different than the naming convention used in the study. However, some EHRs may not permit the listing of the mother’s first name/newborn’s sex before the last name or may allow just one standard format for listing all patient names, including adults. We also do not know the downstream impact of listing newborn names differently than all other patient names. Regardless, the TJC example is just that—an example of how to incorporate the mother’s first name into the newborn’s temporary name to make it more distinct. According to a TJC representative, following the TJC example explicitly is not required to meet the NPSG to use distinctive methods of identification for newborns.11
Errors Since Using the TJC Newborn Naming Convention Example
Since the new NPSG EP related to newborn naming was adopted by TJC, ISMP has received several reports of errors from hospitals that have implemented this change, along with concerns that TJC newborn naming convention example makes the mother’s and newborn’s names too similar. Most of these reported mix-ups have been between the mother and newborn, rather than between different newborns with similar names.
One hospital reported three cases of confusion that almost led to errors since changing their newborn naming convention to include the mother’s first name (e.g., from “Smith, Babygirl” to “Smith, Judy Baby Girl” [born to mother Smith, Judy]) in response to the TJC NPSG requirement. One event involved confusion regarding whether an order for an echocardiogram was intended for the mother or newborn. The other two close calls involved confusion with parenteral nutrition (PN), which was an outsourced product. In both cases, temporary, distinct names of the newborns that incorporated the mothers’ names (e.g., “Smith, Judy Baby Girl”) had been used in the EHR. However, pharmacy staff were aware of the newborns’ given first names and used them to enter the PN orders into a separate order entry system that was integrated with the outsourcer. This led to difficulty with matching the name on the EHR to the name on the outsourced PN labels.
In another hospital, an order for RHOPHYLAC (Rho[D] immune globulin) 1,500 units (300 mcg) intravenously (IV) intended for the mother was accidentally entered into her newborn’s EHR. While reviewing the order, a staff pharmacist consulted with a clinical pharmacist and both agreed that the order was likely an error. The resident was then called, and it was determined that the medication was intended for the mother, not the newborn. The nurse had already clarified the order with the resident, entered the order in the mother’s EHR, and administered the medication correctly to the mother. However, the medication was never discontinued in the newborn’s EHR. Fortunately, the newborn did not receive the medication, as the order had remained unverified by the pharmacy. Investigation revealed that a recent change to include the mother’s first name in the newborn’s name increased the similarity between the newborn’s and the mother’s name, although the format (e.g., “Smith, Girl Judy”) was different than the example provided by TJC (e.g., “Smith, Judy Girl”).
In a third hospital that recently changed its newborn naming convention per the TJC NPSG, an order for surfactant for a newborn was mistakenly placed in the mother’s EHR. It was not until the drug reached the birthing unit that a nurse realized that the order had been erroneously placed in the mother’s EHR. Again, the mother’s first name embedded in the newborn’s identification (e.g., “Smith, Judy Girl”) led to confusion when pulling up the correct patient during order entry.
Previous to these recently reported errors, a hospital identified similar hazards after changing its temporary newborn naming convention to make it more distinct by including the mother’s first name, as recommended in the TJC Quick Safety advisory.6 The hospital had switched from identifying newborns with the mother’s last name and newborn’s sex (e.g., “Smith, Girl” or “Smith, Girl 1” and “Smith, Girl 2” for multiples) to the mother’s last name, mother’s first name, and newborn’s sex (e.g., “Smith, Judy Girl” or “Smith, Judy Girl 1” and “Smith, Judy Girl 2” for multiples). Shortly thereafter, a nurse noticed that both the sex and birth order of an identical twin was missing on the newborn’s name bracelet due to the length of the mother’s last and first names (e.g., “Supercalifragil, Melissa Girl 2” was displayed without “Girl 2”). The same truncated name was on the other female twin’s name bracelet, so both newborns had the same identifying name, which was also the same as their mother’s name.
Based on this, the hospital decided to embed the newborn’s sex before the mother’s first name (e.g., “Supercalifragil, Girl 2 Melissa”), so important newborn identifiers would be less likely to be truncated and missing on the newborn’s name bracelet, regardless of the length of the mother’s first and last names. However, another close call happened in which a nurse inadvertently entered a telephone order for IV labetalol 80 mg TID intended for a postpartum mother with an elevated blood pressure into her newborn’s EHR. Fortunately, a pharmacist reviewing the order recognized that the dose of labetalol was high even for an adult and uncovered the error, so the newborn did not receive the medication.
A few months later, a nurse noticed that the sex in a newborn’s name was missing in the EHR (e.g., “Girl” missing in “Smith, Girl Judy”), so the name of the newborn appeared exactly as the mother’s name (e.g., “Smith, Judy”). Investigation showed that a physician office staff member who was scheduling the newborn’s follow-up appointment upon discharge had removed the sex in the EHR, mistakenly believing that the mother’s first name was the newborn’s given name. Physician office staff were not aware of the recent change in the newborn naming convention at the hospital and had often changed the name of the newborn when a post-discharge appointment was made.
After these errors, the hospital felt that embedding the mother’s first name in the newborn naming convention was creating more look-alike names than previously noted. Further analysis identified other factors contributing to the potential for confusion between the mother’s and newborn’s identity. For example, staff felt that moving the newborn’s sex to the middle of the name made it easier to overlook from a human factor’s perspective. Also, although dose warnings often appeared on the order entry screen if a drug and dose intended for the mother was accidentally entered into the newborn’s EHR, there was no hard stop to require a reason for overriding the warning, and alert fatigue was widespread due to the prevalence of breastfeeding warnings that appeared when entering medications in these patient populations. Although staff often had more than one EHR open when caring for couplets (mother and baby) and multiples, there was little visual distinction between the mother’s and newborn’s EHR. Customization of EHR screens and patient lists used by nurses had resulted in variable size and widths of columns that sometimes did not display complete names due to space limitations. The hospital also felt the A/B conventions used when naming multiples in utero conflicted with the numbers they used for multiples post-delivery.
Please Take our Survey
Choosing a safe newborn naming convention is complex, and there is no easy solution to the inherent risks associated with misidentifying a newborn (or mother) when temporary names are required. As such, ISMP is extremely interested in learning about newborn naming conventions currently used in hospitals and birthing centers and the challenges that practitioners face in clearly differentiating between the mother and newborn(s), between multiple infants born to the same mother, and between newborns with similar first and last names. Thus, we are conducting a survey to learn as much as we can about the issue.
If your facility offers labor and delivery services and you have experience providing care or services to newborn infants and/or mothers, we would really appreciate your participation in our online survey by June 7, 2019. For your reference, the questions in the online survey can be found on pages 5 and 6 of the PDF version. Once we have analyzed the survey results, we plan to collaborate with an advisory group of experts in the field and provide recommendations regarding how to reduce the risk of wrong-patient errors and misidentification of newborns and mothers.