A Milwaukee NICU renamed babies on wristbands and cut wrong-patient orders 36%

In July 2015 Vox reported on a Pediatrics study from a Milwaukee hospital's neonatal intensive care unit. Babies there normally got wristbands with temporary names such as Babyboy or Babygirl, which lets the hospital provide ID immediately even if parents have not picked a name. One survey cited by Vox found more than 80 percent of NICUs use this type of convention.

The problem is that such names look alike when dozens of babies in a unit share similar last names. In 2013 the researchers began giving each baby a distinct name: a baby born to a mother named Wendy Jackson became Wendysgirl Jackson rather than Babygirl Jackson, to make it easier to identify and harder to confuse with the baby of Brenda Johnson.

Near-identical names raise the chance of picking the wrong patient in electronic orders.

A temporary name is still needed at birth, so the fix keeps the practice and adds distinctiveness.

The change takes no extra staff or money, only different text in the label.

Error-proofing can be a label change when the error comes from lookalike identifiers.

The Pediatrics study published in July 2015 showed a 36 percent reduction in wrong-patient electronic orders, measured as orders retracted within 10 minutes and re-placed by the same doctor for a different patient within the next 10 minutes. Vox said the researchers think the change could prevent thousands of mistakes a year.