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Joint Commission Warns that Temporary Names Put Newborns at Risk

Joint Commission Warns that Temporary Names Put Newborns at Risk

According to a new Quick Safety Report published by the Joint Commission (TJC), the hospital practice of giving newborns temporary names at birth may increase the risk of patient identification errors, a potentially serious safety issue.

TJC reports that temporary name identifiers consisting of a baby’s gender and parent’s last name, e.g., Babygirl Stevens, are not distinct enough and might result in multiple newborns with similar identifiers.

Errors caused by newborn misidentification include:

  • Giving expressed breast milk to the wrong infant.
  • Reading imaging and pathology results for the wrong patient
  • Incorrectly documenting medications, intravenous lines and weights for the wrong patient.
  • Administering blood products to the wrong patients.
  • Collecting lab specimens from the wrong patient.
  • Wrong patient surgery (Joint Commission Sentinel Event data reveals that since 2010 there have been ten reports of circumcision being performed on the wrong newborn patient due to misidentification.)

Causes of newborn misidentification include:

  • Similar-appearing medical record numbers (MRNs)
  • Identical surnames
  • Similar-sounding names

The Joint Commission recommends several actions for hospitals to take to protect newborns from misidentification:

  •  Do not use “Babyboy” or “Babygirl” in temporary newborn name conventions.
  • Adopt an organization-wide, distinct temporary newborn naming convention
    • A recent study published in Pediatrics suggests using the mothers first name followed by the letter “s”, baby’s gender and then mother’s last name: Lorisgirl Stevens)
  • Provide training for staff on approved temporary newborn naming convention.
  • Comply with National Patient Safety Goal 01.01.01 and use two patient identifiers at all times.
  • Once the newborn is named by the parents enter the newborn’s actual name into the medical record instead of continuing to use the temporary name.

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