Abstract:
BACKGROUND:NICU patients have characteristics believed to increase their risk for wrong-patient errors; however, little is known about the frequency of wrong-patient errors in the NICU or about effective interventions for preventing these errors. We conducted a quality improvement study to evaluate the frequency of wrong-patient orders in the NICU and to assess the effectiveness of an ID reentry intervention and a distinct naming convention (eg, "Wendysgirl") for reducing these errors, using non-NICU pediatric units as a comparator. METHODS:Using a validated measure, we examined the rate of wrong-patient orders in NICU and non-NICU pediatric units during 3 periods: baseline (before implementing interventions), ID reentry intervention (reentry of patient identifiers before placing orders), and combined intervention (addition of a distinct naming convention for newborns). RESULTS:We reviewed >850 000 NICU orders and >3.5 million non-NICU pediatric orders during the 7-year study period. At baseline, wrong-patient orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs 74.9 per 100 000 orders, respectively; odds ratio 1.56; 95% confidence interval, 1.34-1.82). The ID reentry intervention reduced the frequency of errors in the NICU to 60.2 per 100 000 (48.7% reduction; P < .001). The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100 000 (61.1% reduction from baseline; P < .001). CONCLUSIONS:The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units. Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.
journal_name
Pediatricsjournal_title
Pediatricsauthors
Adelman JS,Aschner JL,Schechter CB,Angert RM,Weiss JM,Rai A,Berger MA,Reissman SH,Yongue C,Chacko B,Dadlez NM,Applebaum JR,Racine AD,Southern WNdoi
10.1542/peds.2016-2863subject
Has Abstractpub_date
2017-05-01 00:00:00issue
5eissn
0031-4005issn
1098-4275pii
peds.2016-2863journal_volume
139pub_type
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