Use of temporary names for newborns and associated risks

Jason Adelman, Judy Aschner, Clyde Schechter, Robert Angert, Jeffrey Weiss, Amisha Rai, Matthew Berger, Stan Reissman, Vibin Parakkattue, Bejoy Chacko, Andrew Racine, William Southern

Research output: Contribution to journalArticlepeer-review

35 Scopus citations


BACKGROUND: Because there can be no delay in providing identification wristbands to newborns, abstract 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.

Original languageEnglish (US)
Pages (from-to)327-333
Number of pages7
Issue number2
StatePublished - Aug 1 2015

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health


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