It can take parents days to name their newborns. In the meantime, hospitals assign temporary names.
Because there are no national standards for assigning these names, many combinations can be used such as “Smith, Babygirl,” “Smith, Baby Marie” (the mother’s first name) or “Smith, BG.” Names in multiple births, which typically vary by only one number or letter, have even more possible combinations. As a result, there are numerous opportunities for errors such as truncation or misreading.
Errors reported due to misidentification include orders placed on the wrong baby’s chart or on the mother’s chart for the baby and vice versa. A 2016 safety advisory found that 11% of newborn medical errors involve misidentification, and in one hospital studied, two misidentification events occurred daily. In addition, the lack of standards makes it difficult for follow-up pediatricians to match a newborn’s electronic hospital record.
The Joint Commission has recognized this problem but only requires using distinct methods of identification. To address this, the American Health Information Management Association (AHIMA) developed simple recommendations that can reduce misidentification.
- For single births, use the baby’s last name, sex and mother’s first name, e.g., “Smith, GirlMarie” or “Smith, BoyMarie.” If the sex is unknown, use “Baby,” e.g., “Smith, BabyMarie”).
- For multiple births, use “Smith, Girl1Marie” (use 2, 3, etc., for the other babies). Note: There are no spaces between the sex, number and mother’s name.
Despite the Joint Commission requirement and AHIMA recommendations, few hospitals have made these changes. While the benefits of national standardization are clear, the following factors contribute to the slow pace of adoption.
Legacy systems and technical challenges
Many health care organizations rely on legacy systems that are incompatible with modern standards. Integrating systems can be complex and time-consuming, especially when dealing with diverse data formats and protocols. Upgrading systems to meet new standards also can be disruptive.
Organizational and cultural factors
Health care organizations often have multiple departments or facilities, leading to fragmented and incompatible data. Employees may be resistant to changes in their workflows or data collection processes. Even within a single organization, there may be inconsistencies in data definitions and collection methods.
Regulatory and policy issues
Health care organizations must comply with various regulations (e.g., the Health Insurance Portability and Accountability Act), which can make it challenging to adopt new standards. The federal government has not yet endorsed the AHIMA recommendation, and the possibility, while unlikely, of a different standard in the future can create confusion and hinder adoption.
Lack of resources and expertise
Implementing new standards can be costly, and many health care organizations may lack the necessary resources. Furthermore, the technical skills required to implement and maintain standardized data systems may be in short supply.
Overcoming these challenges sometimes is a matter of awareness. Pediatricians who see newborns or are involved in informatics can champion adoption of the AHIMA recommendations in their hospitals and nationally. In addition, state organizations can convene groups to encourage standardization of newborn naming conventions for the safety of all newborns.
Dr. Schneider and Dr. Simonian are members of the AAP Council on Clinical Information Technology.