Effect of an Alternative Newborn Naming Strategy on Wrong-Patient Errors: A Quasi-Experimental Study

Ethan Pfeifer, Margaret Lozovatsky, Joanna Abraham, Thomas Kannampallil

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Objectives Newborns are often assigned temporary names at birth. Temporary newborn names-often a combination of the mother's last name and the newborn's gender-are vulnerable to patient misidentification due to similarities with other newborns or between a mother and her newborn. We developed and implemented an alternative distinct naming strategy, and then compared its effectiveness on reducing the number of wrong-patient orders with the standard distinct naming strategy. Methods This study was conducted over a 14-month period in the newborn nursery and neonatal intensive care units of three hospitals that were part of the same health care system. We used a quasi-experimental study design using interrupted time series analysis to compare the differences in wrong-patient orders (an indicator of patient misidentification) before and after the implementation of the alternative distinct naming strategy. Results Overall, there were 25 wrong-patient errors per 10,000 orders during entire study period (36.8 per 10,000 before and 19.6 per 10,000 after). However, there was no statistically significant change in the rate of wrong-patient ordering errors after the transition from the distinct to the alternative distinct naming strategy (β = 0.832, 95% confidence interval [CI] = -0.83 to 2.49, p = 0.326). We also found that, overall, 1.7% of the clinicians contributed to 62% of the wrong-patient errors. Conclusion Although we did not find statistically significant differences in wrong-patient errors, the alternative distinct naming approach provides pragmatic advantages over its predecessors. In addition, the localization of wrong-patient errors within a small set of clinicians highlights the potential for developing strategies for delivering training to clinicians.

Original languageEnglish
Pages (from-to)235-241
Number of pages7
JournalApplied clinical informatics
Issue number2
StatePublished - Mar 1 2020


  • newborn naming
  • patient misidentification
  • segmented regression
  • wrong-patient errors


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