title: Use of Temporary Names for Newborns and Associated Risks.
abstract: BACKGROUND
  Because there can be no delay in providing identification wristbands to newborns, some hospitals assign newborns temporary first names such as Babyboy or Babygirl. These nondistinct naming conventions result in a large number of patients with similar identifiers in NICUs. To determine the level of risk associated with nondistinct naming conventions, we performed an intervention study to evaluate if assigning distinct first names at birth would result in a reduction in wrong-patient errors.
  
  
  METHODS
  We conducted a 2-year before/after implementation study to examine the effect of a distinct naming convention that incorporates the mother's first name into the newborn's first name (eg, Wendysgirl) on the incidence of wrong-patient errors. We used the Retract-and-Reorder (RAR) tool, an established, automated tool for detecting the outcome of wrong-patient electronic orders. The RAR tool identifies orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient within the next 10 minutes.
  
  
  RESULTS
  The reduction in RAR events post- versus preintervention was 36.3%. After accounting for clusters of orders within order sessions, the odds ratio of an RAR event post- versus preintervention was 0.64 (95% confidence interval: 0.42-0.97).
  
  
  CONCLUSIONS
  The study results suggest that nondistinct naming conventions are associated with an increased risk of wrong-patient errors and that this risk can be mitigated by changing to a more distinct naming convention.
authors.affiliation: Albert Einstein College of Medicine, Bronx, New York; Montefiore Medical Center, Bronx, New York; jadelman@montefiore.org.
authors.forename: Jason
authors.initials: J
authors.lastname: Adelman
authors.affiliation: Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York;
authors.forename: Judy
authors.initials: J
authors.lastname: Aschner
authors.affiliation: Albert Einstein College of Medicine, Bronx, New York; Department of Family Medicine, Albert Einstein College of Medicine, Bronx, New York; and.
authors.forename: Clyde
authors.initials: C
authors.lastname: Schechter
authors.affiliation: Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York;
authors.forename: Robert
authors.initials: R
authors.lastname: Angert
authors.affiliation: Albert Einstein College of Medicine, Bronx, New York; Montefiore Medical Center, Bronx, New York;
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Weiss
authors.affiliation: Montefiore Medical Center, Bronx, New York;
authors.forename: Amisha
authors.initials: A
authors.lastname: Rai
authors.affiliation: Albert Einstein College of Medicine, Bronx, New York; Montefiore Medical Center, Bronx, New York;
authors.forename: Matthew
authors.initials: M
authors.lastname: Berger
authors.affiliation: Montefiore Medical Center, Bronx, New York;
authors.forename: Stan
authors.initials: S
authors.lastname: Reissman
authors.affiliation: Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan.
authors.forename: Vibin
authors.initials: V
authors.lastname: Parakkattu
authors.affiliation: Montefiore Medical Center, Bronx, New York;
authors.forename: Bejoy
authors.initials: B
authors.lastname: Chacko
authors.affiliation: Montefiore Medical Center, Bronx, New York; Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York;
authors.forename: Andrew
authors.initials: A
authors.lastname: Racine
authors.affiliation: Albert Einstein College of Medicine, Bronx, New York; Montefiore Medical Center, Bronx, New York;
authors.forename: William
authors.initials: W
authors.lastname: Southern
mesh_terms: D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D009275:Names; D010355:Patient Identification Systems / Q000379:methods*; D012306:Risk; D013997:Time Factors