Departments of Medicine and Biomedical Informatics, Columbia University Medical Center, New York, New York;
Division of Quality and Patient Safety, NewYork-Presbyterian Hospital, New York, New York.
Pediatrics. 2017 May;139(5). doi: 10.1542/peds.2016-2863.
NICU patients have characteristics believed to increase their risk for wrong-patient errors; however, little is known about the frequency of wrong-patient errors in the NICU or about effective interventions for preventing these errors. We conducted a quality improvement study to evaluate the frequency of wrong-patient orders in the NICU and to assess the effectiveness of an ID reentry intervention and a distinct naming convention (eg, "Wendysgirl") for reducing these errors, using non-NICU pediatric units as a comparator.
Using a validated measure, we examined the rate of wrong-patient orders in NICU and non-NICU pediatric units during 3 periods: baseline (before implementing interventions), ID reentry intervention (reentry of patient identifiers before placing orders), and combined intervention (addition of a distinct naming convention for newborns).
We reviewed >850 000 NICU orders and >3.5 million non-NICU pediatric orders during the 7-year study period. At baseline, wrong-patient orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs 74.9 per 100 000 orders, respectively; odds ratio 1.56; 95% confidence interval, 1.34-1.82). The ID reentry intervention reduced the frequency of errors in the NICU to 60.2 per 100 000 (48.7% reduction; < .001). The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100 000 (61.1% reduction from baseline; < .001).
The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units. Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.
新生儿重症监护病房（NICU）的患者具有被认为会增加其发生错误患者错误的风险的特征；然而，对于 NICU 中错误患者错误的发生频率或预防这些错误的有效干预措施知之甚少。我们进行了一项质量改进研究，以评估 NICU 中错误患者医嘱的发生频率，并评估重新输入患者 ID 和使用独特命名惯例（例如，“Wendysgirl”）的干预措施的有效性，以降低这些错误，同时将非 NICU 儿科病房作为对照组。
使用经过验证的衡量标准，我们在三个阶段检查了 NICU 和非 NICU 儿科病房中错误患者医嘱的发生率：基线期（在实施干预措施之前）、重新输入患者 ID 干预期（在下达医嘱之前重新输入患者标识符）和联合干预期（为新生儿添加独特命名惯例）。
在 7 年的研究期间，我们审查了超过 850000 份 NICU 医嘱和超过 350 万份非 NICU 儿科医嘱。在基线期，NICU 中错误患者医嘱的发生频率高于非 NICU 儿科病房（分别为每 100000 份医嘱 117.2 份和 74.9 份；优势比 1.56；95%置信区间，1.34-1.82）。重新输入患者 ID 的干预措施将 NICU 中的错误频率降低至每 100000 份 60.2 份（减少 48.7%；<0.001）。联合重新输入患者 ID 和独特命名的干预措施使错误率进一步降低至每 100000 份 45.6 份（与基线相比减少 61.1%；<0.001）。
NICU 中错误患者医嘱的风险明显高于非 NICU 儿科病房。实施联合重新输入患者 ID 干预措施和独特命名惯例大大降低了这种风险。
