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Sometimes easy fixes are best to prevent medical error

| Aug 9, 2015 | Medical Malpractice |

A rough estimate of the number of babies born every day in the United States runs around 10,600. In North Carolina, the average rate is about four a day. Mix-ups due to misidentification don’t happen too often, but they have and can.

We’re sure everyone has heard stories of twins separated at birth or being sent home with the wrong parents. Worse yet are the cases where newborns in neonatal intensive care units become the victims of medical error that causes them harm or worse. In some cases, these situations fall into the category of a never event — the kind of thing that simple hospital policies should be able to prevent if they are followed strictly.

They don’t have to be complicated processes, as a case study that recently made it into the journal Pediatrics confirms. Sometimes it just means making one small adjustment that improves communication and reduces the chance of a mistake being made.

The setting was a NICU at a hospital in Milwaukee. What the hospital wanted to do was reduce the risk that one of the vulnerable infants in its care might be harmed because of a misidentification. And a check of records showed that potentially wrong treatment orders were reduced by 36 percent.

All the hospital did was change the naming convention that is used in about 80 percent of all NICUs around the country for infants who have yet to get a formal name. Instead of using the generic identifier of “Babyboy (last name)” or “Babygirl (last name)” the staff went to “Brendasgirl (last name)” or “Wendysboy (last name).”

The simple addition of the mother’s name made babies easier to identify and reduced potential errors. The researchers say this easy change to wristband labels could help avoid thousands of mistakes across the country.

That would seem to be a huge positive return on a very small investment.

Source:, “How one hospital protected newborn babies from medical errors — just by changing their wristbands,” Sarah Kliff, July 25, 2015


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