NCT03960099

Pictographs for Preventing Wrong-Patient Errors in NICUs

Recruiting now NA Last updated 16 March 2026

What this trial tests

NA trial testing Pictograph in Banner and Verification Alert in Medical Errors in 6,250 participants. Currently enrolling.

Timeline

16 March 2022

Primary endpoint
30 June 2027

30 June 2028

Quick facts

Lead sponsor	Columbia University
Phase	NA
Status	Recruiting now
Study type	INTERVENTIONAL
Allocation	randomized
Design	parallel
Masking	none
Primary purpose	health services research
Enrollment	6,250
Start date	16 March 2022
Primary completion	30 June 2027
Estimated completion	30 June 2028
Sites	4 locations across United States

Drugs / interventions tested

• Pictograph in Banner and Verification Alert

Conditions studied

• Medical Errors — all drugs for Medical Errors →
• Electronic Medical Records — all drugs for Electronic Medical Records →

Sponsor

Columbia University

Who can join

Eligibility, any sex, with Medical Errors or Electronic Medical Records. Patients with the condition only — healthy volunteers not accepted.

Sponsor's own description

Newborns in the neonatal intensive care unit (NICU) are at high risk for wrong-patient errors. Effective 2019, The Joint Commission requires that health systems adopt distinct methods of newborn identification as part of its National Patient Safety Goals. Displaying patient photographs in the electronic health record (EHR) is a promising strategy to improve identification of children and adults, but is unlikely to be effective for identifying newborns. This study assesses the use of Pictographs as a "photo equivalent" for improving identification of newborns in the NICU.

This multi-site, two-arm, parallel group, cluster randomized controlled trial will test the effectiveness of Pictographs for preventing wrong-patient order errors in the NICU. Pictographs consist of three elements: 1) pictorial symbols of easy-to-remember objects (e.g., rainbow, lion); 2) the infant's given name (when available); and 3) a color-coded border indicating the infant's sex. The study will be conducted at three academic medical centers that utilize Epic EHR. All parents or guardians will be asked to select a unique Pictograph for each infant admitted to the NICU to be displayed on the isolette and in the EHR for the duration of the infant's hospital stay. All clinicians with the authority to place electronic orders in the study NICUs will be randomly assigned to either the intervention arm (Pictographs displayed in the EHR) or the control arm (no Pictographs displayed in the EHR). The main hypothesis is that clinicians assigned to view Pictographs in the EHR will have a significantly lower rate of wrong-patient order errors in the NICU versus clinicians assigned to no Pictographs.

The primary outcome is wrong-patient order sessions, defined as a series of orders placed for a single patient by a single clinician that contains at least one wrong-patient order. The Wrong-Patient Retract-and-Reorder (RAR) measure, a validated, reliable, and automated method for identifying wrong-patient orders, will be used as the primary outcome measure. The Wrong-Patient RAR measure identifies one or more orders placed for a patient that are retracted within 10 minutes, and then reordered by the same clinician for a different patient within the next 10 minutes. In the validation study conducted at a large academic medical center, real-time telephone interviews with clinicians confirmed that 76.2% of RAR events were correctly identified by the measure as wrong-patient orders.

Publications & conference data

No peer-reviewed publications indexed yet for this trial.