Presentation
Design, Evaluation, and Implementation of An Unidentified Patient Naming Convention
DescriptionThere are several common scenarios in day-to-day hospital operations that require an unidentified identity to be assigned to a patient in the electronic health record (EHR). Examples include: 1) a trauma patient arriving via ambulance who needs patient care immediately upon arrival at the Emergency Department, or 2) a patient arrives at the Emergency Department without a legal driver’s license or any other identification documentation. It is very likely the unidentified identity (e.g., the DOE name and the DOE date of birth) is kept in the EHR for the patient’s entire hospital stay because any change of the core demographics can create discrepancies and invalidate the patient’s active Type and Screen orders. Therefore, the unidentified naming convention must be well designed which could have major impacts on the patient’s journey in the hospital.
It is important to create a DOE naming convention that facilitates safe communication and workflows, while reducing opportunities for human error. The unidentified naming convention used in each hospital varies (e.g., the use of the car brands, numbers, color names, letter combinations, etc.). One example used the spelled-out number (one to nintynine) as the patient’s last name, the “Doe” as the middle name, and the “NATO” phonetic alphabet as the first name. An example of the patient’s identified name using this convention was “Eightthree, Fig D”. We conducted a work system analysis and identified the following issues with the use of this naming convention.
• Since the Doe name includes a number, clinicians and non-clinicians may mix up that with the room number, creating potential human errors during patient transport.
• Many numbers look the same in their spellings (e.g., Ninetyeight, Ninetynine; Fortythree, Fortyfour), creating errors referring to the wrong patient during communication.
• Sometimes, there are different doe patients with the same name on the same unit, which create serious patient identify safety risks (at rounding, writing orders, or at patient transport for procedures).
Due to the potential human errors with the use of the current naming convention, we designed four versions of a new naming convention system, conducted user testing with prescribers, nurses, technicians, and gathered user feedback. As a result of user testing, we created the following design guidelines for the unidentified naming convention.
• Names should be simple, short, easy to pronounce and spell
• Names should not exist as real patient names (e.g., London)
• Names should be neutral in meaning
• There should be a large size of choices to make it less likely to be duplicated
• Names should be visually and auditorily distinguished with one another
• “Doe” should be as part of the patient’s last name to make it obvious as an unidentified name
Based on the design guidelines, we created additional design versions and gathered user feedback in multiple rounds. We expanded the participants to include frontline users, such as the clinicians in the operating room, clinicians in the emergency department, and non-clinicians at registration and patient identity administration departments in our evaluation. We implemented the following unidentified naming convention as our final design:
• Last names: “US City”-Doe (with more than 150 choices)
• First name: “NATO” phonetic alphabet
The new naming convention design was completed with the selection of name choices according to the design guidelines. We also made policy changes and education/communication material for the implementation. The future steps may include continuous usability testing, the measure of success, and further redesign of the naming conventions.
It is important to create a DOE naming convention that facilitates safe communication and workflows, while reducing opportunities for human error. The unidentified naming convention used in each hospital varies (e.g., the use of the car brands, numbers, color names, letter combinations, etc.). One example used the spelled-out number (one to nintynine) as the patient’s last name, the “Doe” as the middle name, and the “NATO” phonetic alphabet as the first name. An example of the patient’s identified name using this convention was “Eightthree, Fig D”. We conducted a work system analysis and identified the following issues with the use of this naming convention.
• Since the Doe name includes a number, clinicians and non-clinicians may mix up that with the room number, creating potential human errors during patient transport.
• Many numbers look the same in their spellings (e.g., Ninetyeight, Ninetynine; Fortythree, Fortyfour), creating errors referring to the wrong patient during communication.
• Sometimes, there are different doe patients with the same name on the same unit, which create serious patient identify safety risks (at rounding, writing orders, or at patient transport for procedures).
Due to the potential human errors with the use of the current naming convention, we designed four versions of a new naming convention system, conducted user testing with prescribers, nurses, technicians, and gathered user feedback. As a result of user testing, we created the following design guidelines for the unidentified naming convention.
• Names should be simple, short, easy to pronounce and spell
• Names should not exist as real patient names (e.g., London)
• Names should be neutral in meaning
• There should be a large size of choices to make it less likely to be duplicated
• Names should be visually and auditorily distinguished with one another
• “Doe” should be as part of the patient’s last name to make it obvious as an unidentified name
Based on the design guidelines, we created additional design versions and gathered user feedback in multiple rounds. We expanded the participants to include frontline users, such as the clinicians in the operating room, clinicians in the emergency department, and non-clinicians at registration and patient identity administration departments in our evaluation. We implemented the following unidentified naming convention as our final design:
• Last names: “US City”-Doe (with more than 150 choices)
• First name: “NATO” phonetic alphabet
The new naming convention design was completed with the selection of name choices according to the design guidelines. We also made policy changes and education/communication material for the implementation. The future steps may include continuous usability testing, the measure of success, and further redesign of the naming conventions.
Event Type
Oral Presentations
TimeWednesday, March 278:30am - 8:50am CDT
LocationSalon A-1
Hospital Environments