Assessing the Effectiveness of Pictographs for Preventing Wrong-Patient Errors in Neonatal Intensive Care Units: A Randomized Controlled Trial

What this Trial Is About

Newborns in neonatal intensive care units (NICUs) face a high risk of wrong-patient errors, which this research aims to reduce by using Pictographs as a visual identification tool. This study evaluates the use of Pictographs, which are symbols combined with the infant's name and a color-coded border showing sex, to improve newborn identification in the NICU. The trial is a multi-site, cluster randomized controlled study conducted at three academic medical centers using the Epic electronic health record (EHR) system. Parents or guardians select a unique Pictograph for each infant, which is displayed on the infant's isolette and in the EHR during the hospital stay. Clinicians who place electronic orders in the NICU are randomly assigned to two groups: one group sees the Pictographs in the EHR as part of the order process, while the other group does not. The study compares the rate of wrong-patient order errors between these groups using the Wrong-Patient Retract-and-Reorder (RAR) measure, which identifies near-miss ordering errors. Participants include all infants admitted to the NICUs and all ordering clinicians during the study period. Data is collected retrospectively from electronic orders and analyzed to detect wrong-patient order sessions. The study tracks Pictograph use, monitors error rates, and analyzes outcomes at the clinician and NICU levels over approximately 2.5 years. Parents consent verbally, and Pictographs are removed after infant discharge. This trial aims to provide evidence on whether Pictographs reduce wrong-patient errors in NICUs.

Pictographs for Preventing Wrong-Patient Errors in NICUs