Newborn Medication Errors More Likely Due to Hospital Temporary Naming Procedures: Report

Confusing identification methods used in many hospitals for newborns may increase the risk of serious infant medication errors, according to the findings of new research.

A survey by the Institute for Safe Medication Practices (ISMP) indicates that one-third of nurses were aware of errors in the past five years that stemmed from the hospital infant naming procedures.

Researchers from the ISMP conducted a survey from April through September of 2019, including 384 nurses who work in neonatal intensive care units (NICU) and integrated labor, delivery, recovery, postpartum, and newborn units.

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The survey focused on how hospitals and birthing centers use a wide range of methods to assign temporary names to newborn infants for identification purposes. However, the findings suggest many of those naming procedures can lead to errors, where babies are given the wrong medication.

Most hospitals use a naming method that includes the gender and mother’s name, such as Baby Girl Smith or Smith Boy. The methods are typically non-distinct, which results in babies having similar identifiers.

Researchers note that it is difficult for nurses and medical staff to distinguish one newborn form another based on physical appearance or gender, increasing the risk of confusion due to non-distinct identifiers used to name the child.

Roughly 84% of hospitals used the mother’s name in the method for single births. For multiple births, like twins and triplets, three-quarters of hospitals used single letter identifiers and 12% included single numbers.

One-third of all nurses surveyed reported they were aware of medication errors or close calls within the past five years that were linked to newborn naming methods. Most errors occurred when medications were administered. Some errors occurred when the medication was prescribed or where the wrong record was selected.

The most common problems involved confusion between newborn siblings or unrelated newborns with similar first or last names. More than half of nurses surveyed reported being aware of problems staff had with knowing and expressing the infants’ full identity based on the naming method.

For example, many temporary names can be long, difficult to read, or end up truncated or missing information because of character limitations, such as when there is a hyphenated last name.

Sometimes letters are inadvertently left off names, leading to an inability to distinguish between multiple siblings or between the mother and newborn.

The ISMP indicated the most common way to reduce the risk of misidentifying a newborn or mother is by using bar code scanning systems, name alerts, and limiting who can change or merge newborn electronic medical records. However, in some cases, even with these strategies applied errors still occurred.

“ISMP plans to convene an expert advisory group in 2020 to review the survey findings in more depth and make recommendations to prevent misidentification and wrong-patient medication errors with mothers and newborns,” the ISMP news release indicated.


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