Babygirl, Babygirl and Babyboy: Temporary Newborn Names, Wrong-Patient Orders and a Sociotechnical View of Technology and Patient Safety
[Student Name]
University of Phoenix
HSN/376: Health Information Technology for Nursing
Week 5 Assignment
[Instructor Name]
[Date]
The birthing center, the event and the infants are a composite written for a model paper.
Over the past four weeks, I have looked at the electronic record from several angles: how data become decisions, how documentation shapes what the record can show, how decision support can fail and how a system is evaluated after go-live. This final paper uses one near miss to bring those threads together around the course's central question, how technology affects patient safety.
The Near Miss
On a busy night, our newborn nursery held three infants admitted under temporary names: "Babygirl Martinez," "Babygirl Martinez," the second of a set of twins, and "Babyboy Martin." A pediatric provider ordering a bilirubin level for one twin selected the other twin's record from the patient list. The laboratory label printed with the wrong name, and the nurse caught the mismatch when she scanned the label against the infant's band before drawing blood. The order was canceled and replaced. No harm occurred, but the event would have produced a result attached to the wrong infant, and the infant who needed the test would not have had it.
The Evidence on Temporary Names
The problem is not unique to our unit. Newborns must be registered immediately after birth, before they have a first name, so many hospitals assigned temporary names such as Babygirl or Babyboy with the mother's last name. Adelman et al. (2015) studied a distinct naming convention that uses the mother's first name, for example "Wendysgirl," in two neonatal intensive care units over two years. They measured wrong-patient orders with an automated tool that detects an order placed on one patient, retracted within ten minutes and placed by the same clinician on another patient within ten minutes. After the change, these retract-and-reorder events fell by 36.3%, with an odds ratio of 0.64. Accreditation standards then changed: the Joint Commission (2018) required accredited hospitals to use distinct methods of identifying newborns, with the example of including the mother's first name. A naming convention sounds like an administrative detail, but in the record it is the main thing a clinician sees when choosing a patient.
A Sociotechnical Analysis
Sittig and Singh (2010) proposed examining health IT in complex care settings through eight interacting dimensions: the hardware and software; the clinical content inside it; the screens and controls people use; the people themselves; how work and communication flow; the organization's own policies and culture; rules imposed from outside; and how the system is measured and monitored. Their central point is that the dimensions interact, so a safety problem rarely has a single cause. The near miss shows this clearly.
Hardware and software: the record allowed two patients with identical displayed names to appear next to each other on the patient list.
Clinical content: nothing in the system distinguished twins, such as a twin indicator or birth order.
Human-computer interface: the patient list showed name, room and age in hours, and both twins were in the same room and born minutes apart, so every visible identifier matched.
People: the provider was covering two units overnight and ordering for several infants in a row.
Workflow and communication: orders were entered from a workstation away from the bedside, so the provider was not looking at the infant.
Organizational policies: the hospital's naming policy used Babygirl and Babyboy, which was common practice.
External rules: the Joint Commission requirement for distinct newborn identification had been published, but the hospital had not yet changed its policy.
Measurement and monitoring: the hospital did not track retract-and-reorder events, so it had no measure of how often wrong-patient orders were being caught.
The analysis also shows what worked. Bar-code scanning at the bedside, a technology added for safety, caught the error at the last step. Technology created the conditions for the near miss and also caught it.
Why Blame Would Have Missed the Point
A traditional review of this event might have ended with the provider: he selected the wrong patient, so he should be counseled to check two identifiers. That conclusion is true and nearly useless. Every identifier visible on his screen matched both twins, he was doing what the system invited him to do, and the next tired provider on the next busy night would face the same list. Blaming the individual also discourages reporting, and this event was reported only because the nurse who caught it trusted that the report would lead to a fix rather than to discipline. The sociotechnical view does not excuse carelessness, but it directs attention to the conditions that make careful people fail, which are the only conditions an organization can change for everyone at once.
Recommendations
The analysis points to changes in several dimensions at once. The hospital should adopt a distinct naming convention that includes the mother's first name, and add a twin indicator and birth order to the patient banner. The patient list should display a visual warning when two patients have similar names. Bedside scanning of every specimen label should remain mandatory, because it is the last defense. And the hospital should begin monitoring retract-and-reorder events, as Adelman et al. (2015) did, so that it can measure the effect of the change.
The Nurse's Role in Safe Technology
This course has changed how I see my role. Before it, I thought of technology as something the hospital installed and nurses used. The weeks on data, documentation, decision support and evaluation showed that nurses shape how safe technology is: by recording data that can become information, by reporting alerts that no longer help, by noticing workarounds and by catching errors at the bedside, as the nurse in this near miss did. Sittig and Singh's model gives nurses a way to explain a safety event without blaming a single person or a single system, which makes it easier to report and to fix.
Conclusion
A near miss with temporary newborn names shows that technology and patient safety are joined in both directions. The record's design made a wrong-patient order easy, and bar-code scanning at the bedside caught it. A distinct naming convention, supported by evidence and required by the Joint Commission, together with better display and monitoring, would reduce the risk. Safe technology depends on nurses who understand how the parts fit together.
References
Adelman, J., Aschner, J., Schechter, C., Angert, R., Weiss, J., Rai, A., Berger, M., Reissman, S., Parakkattu, V., Chacko, B., Racine, A., & Southern, W. (2015). Use of temporary names for newborns and associated risks. Pediatrics, 136(2), 327-333. https://doi.org/10.1542/peds.2015-0007
Joint Commission. (2018). Distinct newborn identification requirement (R3 Report No. 17).
Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl. 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085
How this HSN 376 Week 5 example is structured
The HSN/376 description makes the relationship between technology and patient safety its key focus, so this final paper takes that relationship as its subject. It analyzes one safety event through a published sociotechnical model rather than blaming either the technology or the nurse, reviews evidence for a specific fix and reflects on what the course taught about the nurse's role in safe technology. Students search this week as HSN 376 Week 5, HSN376 Wk 5 or HSN/376 Wk 5; all three are the same assignment.
HSN/376 Week 5 questions, answered
What does HSN/376 Week 5 usually ask for?
The course description names the relationship between technology in health care delivery and patient safety as its key focus, and many sections close with a paper on that relationship, often analyzing a safety issue involving technology.
Why do temporary newborn names cause errors?
When several newborns share names like Babygirl and the same last name or similar identifiers, clinicians can easily select the wrong record in the electronic system, especially when twins or several infants are in the unit.
What is a sociotechnical model?
A way of analyzing health information technology that treats technology, people, workflow, organization and external rules as interacting parts, so that safety problems are traced to how the parts fit together rather than to one cause.
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