# Effectiveness of Pictographs to Prevent Wrong-Patient Errors in the NICU

> **NIH NIH R01** · COLUMBIA UNIVERSITY HEALTH SCIENCES · 2020 · $668,937

## Abstract

Wrong-patient errors pose a serious threat to patient safety, and newborns in the neonatal intensive
care unit (NICU) are at greatest risk. Half of infants in the NICU on any given day are estimated to be at risk of
a wrong-patient error as a result of having similar identifiers. A major contributing factor is the use of
temporary, nondistinct first names, e.g., Babyboy/Babygirl, that are assigned to newborns at birth and remain
unchanged throughout their hospital stay. Use of a distinct newborn naming convention that incorporated the
mother’s first name (e.g., Wendysgirl) reduced the risk of wrong-patient orders in the NICU by 36%. However,
the distinct naming convention conferred benefit only for singletons—multiple births remained at high risk as a
result of siblings sharing the same name distinguished by a single character (e.g., 1Wendysgirl, 2Wendysgirl).
 Displaying patient photographs in electronic health records (EHRs) is a promising strategy to improve
patient identification. However, photographs are unlikely to be an effective identifier in the NICU where an
additional identifier is urgently needed. In place of patient photographs, we propose BabySAFE Pictographs
as a “photo equivalent” for newborns in the NICU. Pictographs consist of three elements: 1) a pictorial image of
a readily identifiable, distinctive, and easy-to-remember object; 2) the infant’s given name; and 3) a color-
coded border indicating the infant’s sex. Pictographs will be displayed at the bedside and in the EHR to serve
as a visual cue when providers place orders. Parents will select a Pictograph for their infants for the duration of
their hospital stay, with no two infants having the same Pictograph at the same time in the same NICU.
 We propose conducting a cluster randomized controlled trial to assess the effectiveness of Pictographs
for reducing wrong-patient orders in the NICU. We will use the automated Wrong-Patient Retract-and-Reorder
measure, developed and validated by the Principal Investigator of this proposal, as the primary outcome
measure. Our main hypothesis is that Pictographs will reduce the frequency of wrong-patient orders in the
NICU, including among siblings of multiple births. We propose the following specific aims:
 Aim 1: To conduct a multi-site, cluster randomized controlled trial to compare the frequency of wrong-
patient orders in the NICU between providers randomized to view verification screens with versus without
BabySAFE Pictographs, as identified by the Wrong-Patient Retract-and-Reorder measure.
 Aim 2: To conduct subgroup analyses of the effectiveness of BabySAFE Pictographs for reducing the
frequency of wrong-patient orders among siblings of multiple births in the NICU.
 Aim 3: To conduct a qualitative evaluation to examine the perceptions and experiences of healthcare
providers and parents about BabySAFE Pictographs as an additional identifier for newborns in the NICU.
 This proposal addresses research gaps identified by the Nationa...

## Key facts

- **NIH application ID:** 9980442
- **Project number:** 5R01HD094793-03
- **Recipient organization:** COLUMBIA UNIVERSITY HEALTH SCIENCES
- **Principal Investigator:** Jason Stuart Adelman
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $668,937
- **Award type:** 5
- **Project period:** 2018-08-08 → 2023-07-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9980442

## Citation

> US National Institutes of Health, RePORTER application 9980442, Effectiveness of Pictographs to Prevent Wrong-Patient Errors in the NICU (5R01HD094793-03). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9980442. Licensed CC0.

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