Patient Safety Research Program Gives Quintuplets Pictographs to Help Prevent Errors

May 13, 2019

While research has shown that newborns in the neonatal intensive care unit (NICU) are at increased risk for wrong-patient errors, the patient safety research team found that multiples are at even higher risk. Jason Adelman, MD, MS used log data to demonstrate that wrong-patient retract-and-reorder (RAR) events occurred more frequently among multiples (i.e. twins, triplets, etc.) compared to singletons. Wrong-patient RAR events are instances in which a provider places an order for one patient, quickly cancels that order, then places the same order on a different patient. Dr. Adelman, who also serves as the executive director of the Patient Safety Research Program, is pioneering the implementation of more distinctive newborn identification strategies, such as using the mother's name or the newborn's given name, in order to reduce these risks.

The New York Post took note when Dr. Adelman and his team recently implemented one of these strategies when NewYork-Presbyterian delivered its first set of quintuplets since 1992. This strategy involved the use of the pictographs, simple-to-remember images of various objects, which served as a newborn patient's visual identifier. On February 26th, mother Arlette Rivera welcomed quintuplets Sebastian, Sophia, Mathias, Montserrat, and Thiago into the world and assigned each of them a pictograph to help healthcare providers distinguish between each of the five. Sebastian had a baseball as his pictograph, Sophia was assigned the bumblebee, Mathias received the rocket ship, Montserrat was a sunflower, and Thiago was assigned the violin. The five newborns were admitted to the NICU for close monitoring and the pictographs were implemented in their medical records and isolettes, supporting quick and accurate healthcare delivery.

Dr. Adelman commented on the effectiveness of the intervention: “The team was very pleased that given our efforts to minimize confusion between the babies, which included using their given names instead of Baby A, B, C, D, and E and assigning them all pictographs, there were no wrong-patient errors."

With further research, the Patient Safety Research Program hopes to reduce the risk of wrong-patient errors for all patients, using targeted strategies for newborns and adults. For more information about Patient Safety Research Program's work, visit their Our Research page.