Simple change to patient IDs reduced order errors in neonatal ICU

by | Aug 7, 2015 | Medical Malpractice

A new experiment with naming protocols at a neonatal intensive care unit found that medical errors by the NICU’s staff members plummeted thanks to the new naming process. The incredibly study, which is so simple at its heart that it makes you wonder why it isn’t done more often, was performed at a Milwaukee NICU.

Previously, the NICU used a conventional naming approach for newborn babies that needed to be in intensive care. Many of these babies haven’t been named yet by their parents, and thus, the medical professionals in the NICU need to come up with a naming protocol so that they can identify these babies. This means naming each baby “babyboy” or “babygirl” with a number attached as well to differentiate the babies.

This naming method is used by approximately 80 percent of other NICUs. In other words, it is standard protocol for most facilities. But what the Milwaukee NICU realized is that errors were occurring far too often because the staff members were mixing up patients as a result of the generic naming protocol. 

So they implemented a more dynamic naming process, giving the babies more specific names such as “Wendysgirl” or “BabyJackson” to better differentiate them. What the Milwaukee NICU found is that wrong-patient electronic orders dropped by 36 percent under the new naming system.

This is a tremendous solution to a major problem, but it’s also a reminder that medical staff members are human. They make mistakes. That doesn’t excuse those mistakes in any way. To the contrary, it means that those medical professionals should be held accountable for their mistakes.

Source: Vox, “How one hospital protected newborn babies from medical errors — just by changing their wristbands,” Sarah Kliff, July 25, 2015

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