(HealthDay News) — The risk of wrong-patient orders is higher in the neonatal intensive care unit (NICU) vs non-NICU pediatric units, and the risk of errors can be reduced with interventions, according to a study published in Pediatrics.

Jason S. Adelman, MD, from the Columbia University Medical Center in New York City, and colleagues examined the rate of wrong-patient orders in NICU and non-NICU pediatric units before implementing interventions, with an ID reentry intervention (reentry of patient identifiers before placing orders), and with the combined intervention involving addition of a distinct naming convention for newborns. During the 7-year study period, the authors reviewed more than 850,000 NICU orders and more than 3.5 million non-NICU pediatric orders.

The researchers found that wrong-patient orders were more frequent in NICU than non-NICU pediatric units at baseline (117.2 vs 74.9 per 100,000 orders; odds ratio, 1.56). The frequency of errors in the NICU was reduced with the ID reentry intervention to 60.2 per 100,000 (48.7% reduction; P<.001). An additional decrease was seen with the combined ID reentry and distinct naming interventions to 45.6 per 100,000 (61.1% reduction from baseline; P<.001).

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“The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units,” the authors write. “Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.”


  1. Adelman JS, Aschner JL, Schechter CB, et al. Evaluating serial strategies for preventing wrong-patient orders in the NICU. Pediatrics. 2017 Apr 21. doi:10.1542/peds.2016-2863