Evaluating serial strategies for preventing wrong-patient orders in the NICU

Jason S. Adelman, Judy L. Aschner, Clyde B. Schechter, Robert M. Angert, Jeffrey M. Weiss, Amisha Rai, Matthew Alan Berger, Stan H. Reissman, Camille Yongue, Bejoy Chacko, Nina M. Dadlez, Jo R. Applebaum, Andrew D. Racine, William N. Southern

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7 Citations (Scopus)

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.

Original languageEnglish (US)
Article numbere20162863
JournalPediatrics
Volume139
Issue number5
DOIs
StatePublished - May 1 2017

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Pediatrics
Quality Improvement
Odds Ratio
Newborn Infant
Confidence Intervals

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

Cite this

Evaluating serial strategies for preventing wrong-patient orders in the NICU. / Adelman, Jason S.; Aschner, Judy L.; Schechter, Clyde B.; Angert, Robert M.; Weiss, Jeffrey M.; Rai, Amisha; Berger, Matthew Alan; Reissman, Stan H.; Yongue, Camille; Chacko, Bejoy; Dadlez, Nina M.; Applebaum, Jo R.; Racine, Andrew D.; Southern, William N.

In: Pediatrics, Vol. 139, No. 5, e20162863, 01.05.2017.

Research output: Contribution to journalArticle

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, WN 2017, 'Evaluating serial strategies for preventing wrong-patient orders in the NICU', Pediatrics, vol. 139, no. 5, e20162863. https://doi.org/10.1542/peds.2016-2863
Adelman, Jason S. ; Aschner, Judy L. ; Schechter, Clyde B. ; Angert, Robert M. ; Weiss, Jeffrey M. ; Rai, Amisha ; Berger, Matthew Alan ; Reissman, Stan H. ; Yongue, Camille ; Chacko, Bejoy ; Dadlez, Nina M. ; Applebaum, Jo R. ; Racine, Andrew D. ; Southern, William N. / Evaluating serial strategies for preventing wrong-patient orders in the NICU. In: Pediatrics. 2017 ; Vol. 139, No. 5.
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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.",
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AU - Adelman, Jason S.

AU - Aschner, Judy L.

AU - Schechter, Clyde B.

AU - Angert, Robert M.

AU - Weiss, Jeffrey M.

AU - Rai, Amisha

AU - Berger, Matthew Alan

AU - Reissman, Stan H.

AU - Yongue, Camille

AU - Chacko, Bejoy

AU - Dadlez, Nina M.

AU - Applebaum, Jo R.

AU - Racine, Andrew D.

AU - Southern, William N.

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N2 - 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.

AB - 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.

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