Nearly 12% of the more than 4 million newborns in the United States are admitted to a neonatal intensive care unit (NICU) . In addition to their clinical vulnerabilities, a significant patient safety issue in the NICU is patient misidentification, largely attributed to having temporary non-distinct names, similarities in medical record numbers (MRN), and presence of multiples with similar names and identifiers. Similar safety concerns exist for well newborn with the additional challenge of the mother and baby being hospitalized at the same time and the need to differentiate between the two charts. Additionally, the workflows that are unique to each EHR must be considered in these settings. A distinct newborn naming convention is a validated methodology that has shown to decrease wrong patient errors by 36% in multiple organizations, however they were all on the same EHR. Consideration of the workflows in our EHR created a new patient safety concern when it was discovered that, due to character limitations, using the distinct naming convention for newborns could make the header of the infant and the mother appear identical when the charts were opened next to each other, a common occurrence when validating prenatal medical history. While referencing of the maternal chart occurs in the early stages of the NICU admission, it typically occurs throughout the entire admission in the Newborn Nursery. To address this potential safety concern, an alternative distinct newborn naming convention was developed and implemented at BJC Health Care/Washington University. A pre-post evaluation of this alternative distinct naming strategy with the distinct naming strategy by evaluating the incidence of wrong-patient errors is currently being conducted and will be presented. Our experience has demonstrated the importance of the distinct newborn naming convention in preventing wrong patient errors. While the distinct naming methodology is a validated approach, we have learned that it must be modified to address the needs of all settings where newborn care is provided and the unique workflows of each EHR must be carefully considered.

Describe the new knowledge and additional skills the participant will gain after attending your presentation.: After attending this presentation, an attendee will be able to understand:

(a) various newborn naming conventions
(b) potential risks associated with each naming convention
(c) an alternate distinct naming convention that potentially affords minimal risk for wrong-patient errors and
(d) findings from a preliminary evaluation of using the alternate distinct strategy


Margaret Lozovatsky (Presenter)
BJC Health Care - Washington University School of Medicine

Thomas Kannampallil, BJC Health Care - Washington University School of Medicine

Presentation Materials: