Mother-Baby Errors: A Potential Unintended Consequence of Distinct Newborn Naming Conventions [24O

Abstract

INTRODUCTION: To prevent wrong-patient errors, The Joint Commission issued a requirement in 2019 that hospitals use distinct methods of newborn identification, such as incorporating the mother's first name into the newborn' name (eg, Jackson, Wendysgirl). However, since the requirement went into effect, there have been reports of wrong-patient errors between mother-baby dyads as an unintended consequence of having similar names. METHODS: The purpose of this study was to quantify the rate of mother-baby errors, using a validated measure of near-miss, wrong-patient orders. The Wrong-Patient Retract-and-Reorder measure identifies orders placed for a patient that are canceled and reordered by the same clinician for a different patient shortly thereafter. We examined all orders placed for women and newborns who were inpatients at the same time after delivery from 1/1/2015–12/31/2018 at a large academic medical center that used the required newborn naming convention over the entire study period. RESULTS: The analysis included a total of 5,953,738 orders placed for 59,737 mother-baby dyads. Overall, there were 311 wrong-patient orders (mean 77.8 per year), for a rate of 5.2 per 100,000 orders. Order errors occurred in 84 mother-baby dyads; in 77 dyads, orders placed for the mother were intended for the newborn, most commonly vaccines and newborn screens. Orders placed for the newborn intended for the mother included antihypertensives, anticoagulants, and opioids. CONCLUSION: These results provide further evidence of mother-baby errors related to newborn naming conventions. Although these were near-miss errors, the outcome of such errors reaching the patient could be catastrophic in this setting.