What’s in a Name? Survey Finds Wide Variety of Error-Prone Newborn Naming Conventions in Use Today
In our April 25, 2019 newsletter, we described unique risks associated with the newborn naming convention used in hospitals and birthing centers that have led to wrong-patient errors. Because newborn identification is a priority immediately after birth, healthcare providers typically employ a newborn naming convention that assigns a temporary, nondistinct first name (e.g., Baby Boy), plus the mother’s name, to identify newborns. This results in patients with similar identifiers, including mothers and newborns with the same last names, and infants with the same nondistinct first names. Fraternal twins and higher-order multiples are at particularly high risk of misidentification errors because they have the same birthdate, gender, and last name, and they often have medical record numbers differentiated by only one number since they are created in numerical order based on the time of birth.
Other unique conditions with the newborn population can also increase the risk of wrong-patient errors. First, it is often difficult to distinguish one newborn from another based on physical appearance or gender, and they cannot participate in the identification process. Next, each newborn’s electronic health record (EHR) must eventually be changed from a temporary to a permanent name after preparing official documentation for a birth certificate. Lastly, long temporary newborn names may be truncated in the EHR and on other documentation (e.g., name bracelets, labels), potentially dropping unique identifiers used to differentiate them from their siblings and/or mothers.
To learn more about newborn naming conventions and the challenges associated with proper identification of mothers and newborns, we conducted a survey this year between the end of April and September. During September, the National Association of Neonatal Nurses (NANN) helped recruit survey participants. The results of the survey suggest that newborn naming conventions are extraordinarily complex, widely varied, and fraught with problems that may continue to lead to misidentification and wrong-patient errors.
ISMP sincerely thanks the 384 respondents who completed our survey. Most respondents were nurses (69%) who work in neonatal intensive care units (NICUs) (56%); integrated labor, delivery, recovery, postpartum, and newborn units (32%); and newborn nurseries (9%). We also want to thank the many prescribers, including nurse practitioners (12%); pharmacists (12%); and others (7%) (e.g., midwives, clinical instructors, administrators, interdisciplinary teams, risk/quality/safety professionals) who participated in our survey.
Newborn Naming Conventions Used
Singletons. Respondents reported extensive variation in the newborn naming conventions used by hospitals and birthing centers. For singletons (a single male or female newborn), respondents reported 75 different naming conventions, irrespective of the use of uppercase or lowercase letters, punctuation or other marks, or spacing between names. More than half of these 75 naming conventions were unique to a single facility. When survey respondents were asked about the naming convention used for a singleton born to “Judy Smith,” the three most common were:
Smith Girl (or Boy) Judy (25%)
Smith BG (or BB) Judy (11%)
Smith Baby Girl (or Boy) (8%)
Two-thirds (68%) of the naming conventions began with the mother’s last name (Smith), 12% began with “Baby,” and the remainder varied widely. Almost two-thirds (65%) of the naming conventions specifically designated that the patient is a newborn, with most using Baby (60%), B (15%), or NB (13%). All respondents included the mother’s last name in the naming convention (one also included the father’s last name).
The mother’s first name was embedded by 84% of respondents, with 1 in 10 signaling that it was the mother’s, not the newborn’s, first name (e.g., of Judy, Judys, Judysgirl, mom Judy, mother Judy). Some respondents (29%) embedded the mother’s first name in the naming convention due to the example provided in the 2018 National Patient Safety Goal (NPSG.01.01.01) by The Joint Commission (TJC). However, most respondents who embedded the mother’s first name in their naming convention were already doing so before the 2018 NPSG. The 16% who did not include the mother’s first name were unaware of the NPSG, had not gotten around to making the change, or felt their naming convention was safer (e.g., worried about character limitations in electronic presentations).
Only 3% of respondents did not include the newborn’s gender in the naming convention (e.g., Smith Baby Judy). However, among those who did, Girl or Boy (75%) and G or B (19%) were the most commonly used expressions. Five percent of respondents reported that their naming system automatically assigns an A(a) or 1 identifier for singletons (e.g., Smith G1 Judy, Smith Girl A Judy); several commented on the confusion this causes since these designations are usually reserved for the firstborn of multiples.
Multiples. Respondents reported even more extensive variation in the newborn naming conventions used by hospitals and birthing centers for multiples (siblings of the same or different gender). Respondents reported 138 different naming conventions, irrespective of the use of uppercase or lowercase letters, punctuation or other marks, or spacing between names. Almost three-quarters of these 138 naming conventions were unique to a single facility. When survey respondents were asked about the naming convention used for multiples born to “Judy Smith,” the three most common were:
Smith Girl (or Boy) A Judy and Smith Girl (or Boy) B Judy (14%)
Smith Baby Girl (or Boy) A and Smith Baby Girl (or Boy) B (5%)
Smith BG (or BB) A Judy and Smith BG (BB) B Judy (4%)
While most respondents (70%) used single letter identifiers (e.g., A, B, C) to distinguish between multiples, some (12%) used single numbers (e.g., 1, 2, 3). The remainder used double or triple letters (e.g., AA, BBB), Roman numerals (e.g., I, II, III), included the number sign (#) before the number, or wrote out the numbers (e.g., One, Two, Three). The position of the identifier also varied. One respondent included the identifier at the beginning of the naming convention (e.g., One Boy Judy Smith); 30% included it at the end (e.g., Smith Baby Boy A); and the remainder included it in the middle (e.g., Smith Girl A Judy). Spacing between the identifier and gender, particularly when using abbreviations, was noted to cause confusion (e.g., BA and BB [BB mistaken as baby boy]; BBA and BGB [B at end of BGB mistaken as boy, or B in BBA mistaken as twin B rather than gender]). Distinguishing identifiers (e.g., A/B, 1/2) were always used for multiples of the same gender, although a few respondents noted that the identifier may not be included with the firstborn (e.g., Smith Girl Judy [for firstborn], Smith Girl B Judy [for secondborn]). Fourteen percent of respondents used only gender to differentiate twins that were not the same gender (e.g., Smith Girl Judy and Smith Boy Judy).
Consistency. Most (95%) respondents reported that the same newborn naming convention is used for all applications displaying patient identification information. The few differences were mostly with handwritten forms of identification (e.g., bands placed on newborns at birth, crib cards, name plates). However, several respondents noted concerning differences, such as a documentation system that uses given names and a prescribing system that uses temporary names; pharmacy labels that differ from identification bracelets; variances between the two identification bands on the newborn; and variances from patient to patient.
Replacing Temporary Names with Given Names
Only 5% of respondents reported that they are aware of the newborn’s given name(s) before or immediately after birth at least 95% of the time. Even when given names become available, few respondents reported changing the name mid-admission (14%) or adding the given name in quotation marks to the end of the naming convention (4%); most wait until the newborn is discharged or transferred out of the facility, or they wait at least 7 days if the newborn’s length of stay exceeds a week.
The most common reason for not changing the newborn’s temporary name to the given name was to prevent confusion and misidentification. For example, many respondents mentioned that changing names mid-admission and creating a second medical record for the newborn could pose a risk, particularly when prescribing medications, identifying pending diagnostic results and pre-existing blood bank information, identifying previously dispensed medications labeled with the temporary name, documenting care, billing insurance companies, and ensuring that the right infant is discharged to the right mother (in cases where the newborn is given the father’s last name, which may differ from the mother’s last name).
Hazards and Errors
Overall, more than half (57%) of respondents believed that wrong-patient errors could result from the newborn naming convention used in their facility. No significant difference in the perceived risk of errors was noted with respondents who reported changing their naming convention to comply with the example provided in TJC’s NPSG (54%).
In fact, almost one-third of all respondents reported that they were aware of medication errors or close calls associated with their newborn naming convention within the past 5 years (Table 1). The most frequent types of reported events involved mix-ups between newborn siblings or unrelated newborns with similar or the same last names. Most of the reported events occurred during drug administration, although some involved prescribing errors in which the wrong newborn record was selected. More than 10% of respondents were also aware of mix-ups between mothers and their newborns, most of which occurred during the prescribing node.
|Percent (%)||Error Scenario||Examples|
|32||Newborn was prescribed, dispensed, and/or administered a medication intended for a sibling (multiple births)||
|26||Newborn was prescribed, dispensed, and/or administered a medication intended for another unrelated newborn||
|18||Mother was prescribed, dispensed, and/or administered a medication intended for her newborn(s)||
|13||Newborn prescribed, dispensed, and/or administered a medication intended for the mother||
Many respondents also commented that their newborn naming convention often resulted in long temporary names that are difficult to read or have truncated or missing information due to character limitations, particularly with hyphenated last names. In the past 5 years, 55% of respondents were aware of problems with expressing the full identity of newborns. Among these, almost three quarters (70%) said that this has resulted in losing a character that distinguishes multiples (e.g., “…BabyboyA” truncated as “…Babybo”), and 34% reported that this has resulted in the inability to distinguish between the mother and infant (e.g., “…Melissa Girl” truncated as “…Melissa”). NICU nurses (23%) reported fewer problems with distinguishing between the mother and infant since they do not provide care to mothers. Respondents who now embed the mother’s first name in their naming convention based on the 2018 NPSG example reported more frequent problems: 84% said the increase in the length of the naming convention has resulted in losing a character that distinguishes multiples; and 48% reported the inability to distinguish between the mother and infant.
The most frequently reported strategies used to reduce the risk of misidentifying mothers and newborns when prescribing, dispensing, and administering medications are employing barcode scanning systems, utilizing name alerts, and limiting who can change/merge newborn EHRs (Table 2). Other strategies reported by at least 1 in 3 respondents were limiting access to patient records to only those appropriate for the practitioner and establishing hard stops or documentation of the reason for overriding electronic alerts that may signal a potential mix-up between the mother and newborn. The least frequently reported strategies involved the use of specialized text, formatting, spacing of text, or customized screen backgrounds to distinguish newborns or enhance the display of complete information.
|Strategies||Percent (%) Implementation|
|Employ bedside barcode scanning systems for mothers and newborns||94|
|Employ name alerts||87|
|Limit who can change/merge newborn EHRs||78|
|Limit access to patient records to only those appropriate for the practitioner||49|
|Establish hard stops or require documentation of a reason for overriding electronic alerts that may signal a potential mix-up between mother and newborn||41|
|Employ different formatting of text (e.g., types, cases, and/or sizes of fonts; bolding; color) to distinguish newborns (e.g., Baby GIRL, Babygirl)||23|
|Customize screen backgrounds (e.g., color, highlighting of newborn and age) to better distinguish between mother and newborn records||17|
|Increase the size, width, character spaces used for identification to enhance the display of complete information||13|
More than 1 in 10 respondents reported other strategies not included in our survey to prevent misidentification:
Double banding the newborn (wrist and ankle)
Using different automated dispensing cabinets (ADCs)/medication storage locations for mothers and newborns
Employing independent double checks
Requiring verification of a secondary identification number such as medical record/encounter number
Involving the parents (when present) in the newborn identification process
Using the proper newborn naming convention during every call, report, and encounter
Assigning different nurses to unrelated newborns with the same last name
Failure Modes. Respondents provided numerous examples of conditions that still allowed errors to occur despite these strategies. For barcode scanning, several respondents commented that the task in their location does not occur in real time and is basically used after administration only to facilitate electronic documentation of drug administration. Several respondents noted that identification bands are often removed from newborns and attached to the crib, loose in the crib, or reattached to the wrong infant. A few others noted that errors with injectable medications have still occurred between mothers and newborns rooming together because the syringes were mixed up after barcode scanning occurred.
For name alerts, approximately half of the respondents who provided comments noted that only physical name alerts (e.g., on medication locations, patient lists, labels, cribs) are used, not electronic alerts within the health record. Several respondents also commented that the name alerts are not helpful outside of NICU because every mothers’ and newborns’ names are the same. Some noted that the name alerts are only used for unrelated patients. Finally, numerous respondents noted that limiting access to patient records could be dangerous during an emergency and does not work because, often, prescribers and nurses need to access both the mother’s and newborn’s records, particularly if providing care to both.
ISMP plans to convene an expert advisory group to review these survey findings in more detail and to make recommendations to reduce the risk of misidentification and wrong-patient errors with mothers and newborns. We have begun to gather practitioners for the expert advisory group, but if you have expertise in this area and would like to participate, send your contact information to us by clicking here. Look for the work of the advisory group and the resulting recommendations to be published in a 2020 newsletter.