If the parents have not yet decided on a baby’s name, it is common at many hospitals to give the newborn a temporary name such as Babyboy Smith for use in the hospital. The Joint Commission (TJC) is warning that the practice can lead to patient identification errors and should be reconsidered.
Though well-intended, the use of temporary names creates a situation in which multiple babies will have similar identifiers, and they also might have the same or similar dates of birth and gender.
“Newborns also are a unique patient population as they are unable to participate in the identification process. This unique need requires a reliable system that is hardwired among all providers to prevent error,” TJC writes in a recent warning to hospitals. “An example of a typical temporary name is Babyboy Smith, using the baby’s gender and the parent’s last name. This naming convention is not distinct enough to prevent patient identification errors that could result in harm.”
Ten sentinel events related to temporary names have been reported to the TJC since 2010. All were wrong-person surgery and resulted in circumcision being performed on the wrong patient. TJC also cites these additional errors that could occur when temporary baby names are mixed up:
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feeding a mother’s expressed breast milk to the wrong infant;
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reading imaging tests or pathology specimens for the wrong patient;
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incorrect documenting of medications, vascular lines, and patient weight;
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administering blood products to the wrong patient;
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collecting lab specimens from the wrong patient.
The post in TJC’s Quick Safety describes how one hospital experienced a 36.3% reduction in wrong-patient electronic orders by instituting a new way to temporarily name babies. The hospital uses the mother’s first name, followed by the letter “s” and the baby’s gender, then the parent’s last name. An example would be “Judysgirl Smith” or “Amandasboy Adams.”
For multiple births, the hospital adds a number in front of the name so that the babies are named “1Judysgirl Smith” and “2Judysgirl Smith,” for example.
TJC also cites research from one hospital that determined the causes of wrong-patient errors in its neonatal intensive care unit. The hospital traced the errors to similar-appearing medical record numbers, identical surnames, and similar-sounding names.
To lower the risk of misidenti-fication, TJC recommends that hospitals stop using “Babyboy” or “Babygirl” as any part of the temporary name. Hospitals should adopt a method of assigning temporary names that results in more distinct names and change the baby’s medical record as soon as the parents provide the actual name.
The Quick Safety article is available online at http://tinyurl.com/o72xwx8.
