Effectiveness of Pictographs to Prevent Wrong-Patient Errors in the NICU

象形文字可有效防止 NICU 中错误的患者错误

基本信息

批准号：
10440291
负责人：
Jason Stuart Adelman
金额：
$ 64.35万
依托单位：
COLUMBIA UNIVERSITY HEALTH SCIENCES
依托单位国家：
美国
项目类别：
财政年份：
2018
资助国家：
美国
起止时间：
2018-08-08 至 2024-07-31
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10440291
关键词：
Academic Medical Centers Address Admission activity Adopted Birth Birth Order Caring Childhood Code Color Confusion Cues Effectiveness Electronic Health Record Elements First Name Frequencies Funding Funding Opportunities Goals Guidelines Health Personnel Hospitals Image Infant Joints Last Name Lead Length of Stay Measures Medical Errors Medical Records Medication Errors Methods Mothers Multiple Birth Offspring Names National Institute of Child Health and Human Development Neonatal Neonatal Intensive Care Units Newborn Infant Outcome Measure Panthera leo Parents Patients Pediatric Hospitals Perception Perinatal Principal Investigator Procedures Process Provider Publishing Qualitative Evaluations Randomized Randomized Controlled Trials Research Risk Safety Siblings Site Subgroup Surveys System Testing Time Twin Multiple Birth United States Agency for Healthcare Research and Quality Visual design effectiveness analysis effectiveness evaluation effectiveness testing experience high risk improved minimally invasive neonatal patient novel patient safety prevent primary outcome sex symposium

项目摘要

Wrong-patient errors pose a serious threat to patient safety, and newborns in the neonatal intensive care unit (NICU) are at greatest risk. Half of infants in the NICU on any given day are estimated to be at risk of a wrong-patient error as a result of having similar identifiers. A major contributing factor is the use of temporary, nondistinct first names, e.g., Babyboy/Babygirl, that are assigned to newborns at birth and remain unchanged throughout their hospital stay. Use of a distinct newborn naming convention that incorporated the mother’s first name (e.g., Wendysgirl) reduced the risk of wrong-patient orders in the NICU by 36%. However, the distinct naming convention conferred benefit only for singletons—multiple births remained at high risk as a result of siblings sharing the same name distinguished by a single character (e.g., 1Wendysgirl, 2Wendysgirl). Displaying patient photographs in electronic health records (EHRs) is a promising strategy to improve patient identification. However, photographs are unlikely to be an effective identifier in the NICU where an additional identifier is urgently needed. In place of patient photographs, we propose BabySAFE Pictographs as a “photo equivalent” for newborns in the NICU. Pictographs consist of three elements: 1) a pictorial image of a readily identifiable, distinctive, and easy-to-remember object; 2) the infant’s given name; and 3) a color- coded border indicating the infant’s sex. Pictographs will be displayed at the bedside and in the EHR to serve as a visual cue when providers place orders. Parents will select a Pictograph for their infants for the duration of their hospital stay, with no two infants having the same Pictograph at the same time in the same NICU. We propose conducting a cluster randomized controlled trial to assess the effectiveness of Pictographs for reducing wrong-patient orders in the NICU. We will use the automated Wrong-Patient Retract-and-Reorder measure, developed and validated by the Principal Investigator of this proposal, as the primary outcome measure. Our main hypothesis is that Pictographs will reduce the frequency of wrong-patient orders in the NICU, including among siblings of multiple births. We propose the following specific aims: Aim 1: To conduct a multi-site, cluster randomized controlled trial to compare the frequency of wrong- patient orders in the NICU between providers randomized to view verification screens with versus without BabySAFE Pictographs, as identified by the Wrong-Patient Retract-and-Reorder measure. Aim 2: To conduct subgroup analyses of the effectiveness of BabySAFE Pictographs for reducing the frequency of wrong-patient orders among siblings of multiple births in the NICU. Aim 3: To conduct a qualitative evaluation to examine the perceptions and experiences of healthcare providers and parents about BabySAFE Pictographs as an additional identifier for newborns in the NICU. This proposal addresses research gaps identified by the National Institute of Child Health and Human Development, which seeks projects to develop novel and improved methods of neonatal patient identification.

错误的患者错误对患者安全以及新生儿重症监护室的新生儿构成严重威胁据估计，新生儿重症监护病房 (NICU) 中的任何一天都有一半婴儿面临以下风险。由于具有相似的标识符而导致错误的患者错误的一个主要因素是使用。新生儿出生时分配给并保留的临时的、不明确的名字，例如 Babyboy/Babygirl 在住院期间使用独特的新生儿命名约定，其中包含母亲的名字（例如 Wendysgirl）将 NICU 中错误的患者指令的风险降低了 36%。独特的命名惯例只为单身人士带来好处——多胞胎仍然面临着很高的风险。兄弟姐妹共享相同名称并通过单个字符进行区分的结果（例如 1Wendysgirl、2Wendysgirl）。在电子健康记录 (EHR) 中显示患者照片是一种很有前景的策略，可以改善然而，在新生儿重症监护病房 (NICU) 中，照片不太可能成为有效的识别标志。我们迫切需要额外的标识符来代替患者照片。作为 NICU 新生儿的“照片等同物”，象形文字由三个元素组成：1) 的图形图像。易于识别、独特且易于记忆的物体；2) 婴儿的名字；以及 3) 颜色—— 指示婴儿性别的编码边框将显示在床边和电子病历中以供使用。作为供应商下订单时的视觉提示，家长会在整个过程中为他们的婴儿选择一个象形文字。在他们的住院期间，没有两个婴儿在同一 NICU 中同时出现相同的象形文字。我们建议进行整群随机对照试验来评估象形文字的有效性为了减少 NICU 中的错误患者订单，我们将使用自动错误患者撤回和重新排序功能。由该提案的首席研究员开发和验证的衡量标准，作为主要成果我们的主要假设是，象形文字将减少错误患者订单的频率。 NICU，包括多胞胎的兄弟姐妹，我们提出以下具体目标：目标 1：进行多中心、整群随机对照试验，比较错误的频率 NICU 中的患者订单在提供者之间随机查看验证屏幕与不 BabySAFE 象形文字，由错误患者撤回和重新排序措施识别。目标 2：对 BabySAFE 象形文字减少婴儿死亡率的有效性进行亚组分析新生儿重症监护病房 (NICU) 多胞胎兄弟姐妹中错误就诊顺序的频率。目标 3：进行定性评估，以考察人们对医疗保健的看法和体验供应商和家长了解 BabySAFE 象形文字作为 NICU 新生儿的附加标识符。该提案解决了国家儿童健康和人类研究所确定的研究空白 Development，寻求开发新的和改进的新生儿患者识别方法的项目。

项目成果

期刊论文数量（1）

专著数量（0）

科研奖励数量（0）

会议论文数量（0）

专利数量（0）

A National Survey on the Use of Temporary Naming Conventions for Newborns: 5-Year Follow-up.

关于新生儿临时命名约定使用情况的全国调查：五年随访。

DOI：
发表时间：
2020
期刊：
影响因子：
1.6
作者：
Besagar, Sonya;Robles, Patrick Louie A;Manzano, Wilhelmina;Applebaum, Jo R;Goffman, Dena;Adelman, Jason S
通讯作者：
Adelman, Jason S