Using Pictographs to Prevent Wrong-Patient Errors in NICUs

Assessing the Effectiveness of Pictographs for Preventing Wrong-Patient Errors in Neonatal Intensive Care Units: A Randomized Controlled Trial

Not applicable Interventional Columbia University · NCT03960099

This study is testing if using special visual symbols with babies' names can help doctors in NICUs avoid making mistakes about which patient is which.

Quick facts

PhaseNot applicable
Study typeInterventional
Enrollment6250 (estimated)
SexAll
SponsorColumbia University Academic / other
Locations4 sites (Baltimore, Maryland and 3 other locations)
Trial IDNCT03960099 on ClinicalTrials.gov

What this trial studies

This clinical trial evaluates the effectiveness of Pictographs, which are visual symbols combined with an infant's name and a color-coded border, in reducing wrong-patient errors in neonatal intensive care units (NICUs). The study employs a multi-site, two-arm, parallel group, cluster randomized controlled design, comparing clinicians who view Pictographs in electronic health records (EHR) to those who do not. The primary goal is to determine if the use of Pictographs leads to a significant decrease in wrong-patient order errors. Additionally, the study will analyze the effectiveness of Pictographs specifically for siblings of multiple births in the NICU.

Who should consider this trial

Good fit: Ideal candidates for this study are all infants receiving care in participating NICUs during the study period.

Not a fit: Patients who are not receiving care in the NICUs during the study period will not benefit from this intervention.

Why it matters

Potential benefit: If successful, this approach could significantly reduce the incidence of wrong-patient errors in NICUs, enhancing patient safety.

How similar studies have performed: Other studies have shown promise in using visual aids for patient identification, but this specific approach with Pictographs is novel.

Eligibility criteria

Show full inclusion / exclusion criteria
Inclusion Criteria:

* All infants receiving care in the study NICUs for whom an order was placed during the study period.
* All clinicians with the authority to place electronic orders in the NICU and who placed electronic orders during the study period.

Exclusion Criteria:

* None

Where this trial is running

Baltimore, Maryland and 3 other locations

Study contacts

How to participate

  1. Review the eligibility criteria above with your treating physician.
  2. Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
  3. Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.
Conditions Medical ErrorsElectronic Medical Records
Last reviewed 2026-06-15 by the Find a Trial editorial team. Information on this page is for educational purposes and is not medical advice. Always consult qualified healthcare professionals about clinical trial participation.