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How one hospital protected newborn babies from medical errors — just by changing their wristbands


In 2013, researchers working at a Milwaukee hospital made a simple change to the way they identify newborn babies — one that they think could prevent thousands of medical mistakes each year.

Right now, babies in the neonatal intensive care unit, or NICU, often get identification wristbands shortly after their birth with temporary first names such as "Babyboy" or "Babygirl." And that makes sense, because it allows the hospital to immediately provide a newborn with ID, even if his or her parents haven't picked out a name.

This practice is common: One survey finds that more than 80 percent of NICUs use this type of naming convention to identify their newborns.

But there's also a problem with this approach, that researchers in the journal Pediatrics pointed out: Non-distinct names like "babyboy" and "babygirl" can look really similar when dozens of baby boys and baby girls in a given NICU have similar last names, too. Not to mention the babies look pretty similar themselves!


Working in a Milwaukee hospital's NICU, researchers took a different approach: They started giving each baby a distinct name, like the ones in green on the right. A newborn baby born to a mother named Wendy would get a wristband that says "Wendysgirl Jackson" rather than "Babygirl Jackson." The hope was that it would make the baby who belongs to Wendy Jackson easier to identify — and harder to confuse with the baby who belongs to Brenda Johnson.

It seems to have worked. A Pediatrics study published this month showed a 36 percent reduction in wrong-patient electronic orders (these can be identified in medical records as patient orders that are retracted within 10 minutes and then placed by the same doctor for a different patient within the next 10 minutes).

"Our results support the hypothesis that the simple intervention of changing from a non-distinct naming convention to a distinct naming convention can result in a meaningful reduction in wrong patient errors in NICUs," the Pediatrics researchers write.

Unlike other health-care improvements, which often take more staff or money to implement, this one seems relatively easy: Just typing something different into babies' wristband labels can help hospitals prevent thousands of mistakes.

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