Premature babies in incubators neonatal intensive care units make me nervous. My twin brother and I were preemies. As my mother tells it, the hospital mislabeled us, calling me Baby Boy Schulte and my brother Baby Girl Schulte. The mishap later became a family joke, but professionally, as a pediatrician, I know misnaming babies causes medical mistakes and puts an infant at risk.
Infant weights change frequently, making medication dosing complicated and requiring frequent recalculation. In one year I caught five mistakes -- wrong drug or wrong baby or both. The worst part is that one simple detail could help avoid potentially fatal mistakes -- the mother's name. When I look at an infant I want to know whether Baby Boy Jones has a mom named Alice or Sandra making the baby -- Alice's Baby Baby Jones -- and easily identifiable.
There is a very simple reason why babies go unnamed. Most of babies are born fast and parents can take weeks or months to pick that first name. Simply put, the delivery room and the receiving nursery can't wait for a parental decision when the new arrival pops out squalling. The baby immediately needs weighing, Vitamin K shots and a medical exam to assess whether the baby is healthy or sick. Immediately, the clerical staff produces labels declaring that Baby Boy Smith or Baby Girl Garcia has arrived and they label the medical record accordingly.
Just consider, some 12 percent of the 4 million babies born each year spend time in the neonatal intensive care units, NICU. Approximately 59,000 infants and children die annually in the U.S. and 56 percent of the deaths are in the hospital, often in an intensive care unit. Data on pediatric deaths due to medical error is not available.
Recently, neonatologists at Montefiore Medical Center in New York City set out to gauge whether adding the mother's first name reduced medical errors. They started by doing their own survey of pediatricians who work in NICUs and learned more than 80 percent of the NICUs (277, 81.7%) reported using non-distinct naming conventions of Baby Boy or Baby Girl.
The Montefiore doctors examined the theoretical wrong-patient error rates before and after implementation of the distinct naming intervention. By tracking orders placed into the computer system and then retracted and entered for a different patient, what's known as used the Retract and Reorder (RAR) tool. Such incidents are considered near misses and most -- three-fourths -- represent wrong patient errors.
After babies were identified with their full mother's names, the number of near misses declined 36 percent from 59.5 per 100,000 orders to 37.9 per 100,000 orders. The findings of the two-year study appeared in medical journal, Pediatrics.
With apologies to Shakespeare who was sure a rose by any name would still smell as sweet, baby's with their own names are just as sweet and safer. That's why I urge parents to ask about a nursery's procedure for handling Baby Boy and Baby Girl names when picking the delivery hospital.
Joann Schulte is a pediatrician who specializes in public health and epidemiology. She currently works at the North Texas Poison Control Center at Parkland Hospital in Dallas.