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Journal Article > Study
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Adelman JS, Applebaum JR, Southern WN, et al. JAMA Pediatr. 2019 Aug 26; [Epub ahead of print].
A classic study found that the replacing the usual naming convention for newborns ("Babygirl" or "Babyboy") with one incorporating the mother's first name (e.g., "Marysgirl" or "Marysboy") reduced wrong-patient errors. Based on this finding, The Joint Commission issued a National Patient Safety Goal (NPSG) requiring the use of distinct naming systems for newborns. The authors of this study noted that the new standard would still leave multiple-birth infants vulnerable to wrong-patient errors, as most hospitals adopted naming standards that left room for confusion between infants (e.g., twin infants might be named "Marysgirl1" and "Marysgirl2"). Researchers examined the rate of wrong-patient errors in six neonatal intensive care units of two health systems that used the NPSG recommended naming conventions, comparing multiple-birth infants to singleton infants. They measured wrong-patient errors by tracking the rate of orders that were retracted and then immediately reordered for a different patient. The rate of wrong-patient errors was significantly higher among multiple-birth infants, most of which could be explained by intrafamilial errors (e.g., a medication was ordered for one twin when intended for another). The accompanying editorial points out that this study is an important example of carefully assessing the real-world impact of novel policies; in this case, the NPSG likely does protect against wrong-patient errors for singleton infants, but not for multiple-birth infants.
Journal Article > Study
We will not compete on safety: how children's hospitals have come together to hasten harm reduction.
Lyren A, Coffey M, Shepherd M, Lashutka N, Muething S. Jt Comm J Qual Patient Saf. 2018;44:377-388.
Reducing harm often requires implementing multicomponent interventions and engaging frontline staff to make change. Prior research has shown that cross-institutional collaboration can facilitate sharing of data and dissemination of best practices to improve safety. The Children's Hospitals' Solutions for Patient Safety (SPS) Network fosters collaboration across 137 hospitals in the United States and Canada to reduce harm from hospital-acquired conditions and adverse events. Hospitals share their data through SPS and have an opportunity to learn from one another. This study describes the efforts of SPS and concludes that since 2012, an initial group of 33 hospitals has successfully reduced harm across eight conditions by anywhere from 9% to 71%. This represents almost $150 million in savings from harm avoided for an estimated 9000 children. A prior WebM&M commentary discussed a medication error that involved a young infant.