Infant Security News
Dedicated to Preventing Infant
Abductions & Mother / Baby Mix-ups
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Security
Assessments International 2405 Safety,
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VOLUME III NUMBER I January, 2005
“Infant Security News” is SAI’s quarterly
newsletter dedicated to helping hospitals protect their youngest patients. Each edition of this free newsletter will
feature current infant security events in the news, and each issue will analyze
an actual infant abduction or mother/baby mix-up case. Cases are assessed to determine how security
was defeated and preventive measures recommended to prevent
future occurrences.
PREVENTING MOTHER/BABY MIX-UPS
(Best Practices)
The following information is designed to
assist individual hospitals in preventing mother/baby mix-ups through staff
awareness, education and best practices.
MOTHER/BABY MIX-UPS
by Jeff Aldridge, CPP
The happiest time in a new
mother’s life is the anticipated delivery of her new baby. Her greatest fear is that something will
happen before she and her new bundle of joy can return home safely. There is no way to describe the absolute
horror parents go through when they discover the baby that they have taken home
is not theirs. So you may ask… how in
the world can such a thing happen? And
what can hospitals do to prevent such a devastating event?
Of the 4.2 million live
births in the
Mother/Baby Mix-Ups
“Hospital administrators
attribute the mix-up of a baby, given to the wrong mother, as simply ‘human
error’. When this type of event occurs,
the hospital pledges to immediately adopt more safeguards to prevent such
mistakes from happening in the future”.
_______________________________________________________________________
“A state investigator finds
that the placement of an infant with the wrong mother was the result of human
error stemming from the nurse misreading the mother and baby’s ID band”.
___________________________________________________________________
“It’s every mother and
father’s worst nightmare… parents of a newborn discover their baby has been
given to another mother and sent home with the wrong parents. The accidental switch was discovered when the
parents realized their wristbands did not match the one on the baby’s ankle
they brought home from the hospital. The
baby was immediately returned to the rightful parents. Hospital pleads “Human Error” and promised it
will never happen again.”
______________________________________________________________________
“A new mother, who
accidentally breast-fed another mother’s baby, discovered that she had nursed
the wrong baby and that the baby was HIV positive. The victim mother plans to sue the hospital
responsible for the mother/baby mix-up.
The mother of the other baby tested positive for the human
immunodeficiency virus which causes AIDS.
__________________________________________________________________________
One of the most publicized
cases of a mother/baby mix-up occurred at the University of
Virginia Medical Center in 1995.
According to one news report, Rebecca Chittum
and Callie Marie Conley apparently experienced problems with their ID bands
just prior to being discharged. No
evidence was discovered to show that the mother/baby mix-up was intentional. Three years would pass before the mix-up
would be discovered by the parents.
Paula Johnson, mother of one of the babies said too much time had passed
for any of the staff to recall exactly what had happened. She learned that nurses “routinely” misplaced
ID bands. At the time of discharge a
parent noticed that one of the baby’s bands was missing and the other baby’s
band was loosely attached to the baby’s ankle.
___________________________________________________________________________
How do mother/baby mix-ups occur?
The majority of mother/baby
mix-ups occur when a hospital staff member fails to match the baby’s
identification number with the mothers’.
This tragic event occurs in thousands of hospitals throughout the
“Loose ankle band” or “wrist band”
An infant I.D. Band slips off of an infant’s wrist and
is accidentally placed on another infant’s ankle.
Cause:
When an Infant is delivered
in Labor & Delivery the baby’s identification band is securely attached to
the infant’s ankle. After the baby has
been transported to the nursery it begins to lose water retained at birth. Over the next few hours the ankle begins to
shrink, because of water loss. As a
result the infant’s identification band becomes lose and slips off the infant’s
foot. Many Infant bands are not
adjustable; they use holes in the band are for securing the band to the
infant. This type of infant band should
not be used. Once the band is attached
and locked into place, the band cannot be tightened.
Prevention:
An ID band that not only locks, but can also be
tightened, should be used for infant identification. It should be placed on the ankle, not the wrist. One hospital changed their practice of
placing the band on the infant’s wrist after a band slipped off the baby’s
wrist causing the baby to be given to the wrong mother. A new procedure was implemented which
required nurses to place the bracelet on each ankle of the baby, instead of one
on the ankle and one on the baby’s wrist.
Infant I.D. bands should not be place on the infant’s wrist. Place the second band on the baby’s other
ankle. A policy should be developed that
requires staff to constantly check the infant’s band for tautness any time the
baby is picked-up or moved. If your
hospital is considering an Electronic Infant Alarms System, make sure the
system also comes with a mother/baby mix-up alarm feature.
“Unacceptable Nurse/Patient Ratio”
Cause:
A National nursing shortage
continues to adversely affect the hospital’s maternity and pediatric units
forcing hospital staff to work with unsafe nurse-patient staffing ratios. An investigation of one hospital discovered
that the mother/baby unit nurse-patient staffing ratio was a contributing factor
to a mother/baby mix-up. The
investigation of this particular hospital revealed that on one shift a single
nurse was responsible for 16 patients.
The hospital initiated a new policy which requires a second nurse to
verify the baby’s identification number matched the mothers’ before the baby is
allowed to take her baby home by the mother.
A ‘Best Practices’ solution would have hospitals follow the staffing
standard for maternity and pediatric units established by the American Academy of Pediatrics (AAP).
Prevention:
Infant / Mother Matching has to be verified before the
baby can safely be handed over to the mother.
This can be accomplished in one of two ways; by human verification, or
by electronic verification. The human
element requires that adequate staffing is always available and staff are
always appropriately educated and trained to follow protocols, policies, and
procedures. Today’s state-of-the-art
Infant Electronic Protection can protect babies both from abduction and
mother/baby mix-ups. If nurse-patient
staffing ratios cannot be met, electronic verification is essential.
“Failing to follow policies and
procedures”
Before an infant transfer can
be completed the person making the transfer must make absolutely sure that the
baby’s identification number matches the mother’s. Both the mother’s I.D. number and the baby’s
should be the same. Mother/baby mix-ups
occur when the baby’s I.D. number is not matched to the mothers’, or the
numbers are incorrectly matched. Babies
are placed in harms way when employees and staff fail to follow policy or are
absent-minded or inattentive to detail.
Causes / Examples:
1) A nurse pushes the mother’s
baby into the room in a bassinet, but fails to verify the infant I.D. band with
the mother because the mother is asleep.
The mother receives the wrong baby.
2) Another nurse enters the
mother’s room, reads the infant’s I.D. number to the mother and has the mother
check her band, but she or he does not require the mother to read back the
number on her band for verification. The
room may be dimly lit and the mother may still be under the influence of
medication that was given during delivery.
She receives the wrong baby.
3) A nurse arm carries a baby
into a treatment room and leaves the empty bassinet in the hallway. A second empty bassinet is left in the same
hallway while the baby is being weighed.
The first nurse brings her baby back to the bassinet, but does not check
the crib card and places her baby in the wrong bassinet. Another mother/baby mix-up has just
occurred.
4) Two babies in infant warmers
are placed side by side. At some
point-in-time, the babies kicked their I.D. bands off their feet. A nurse working in the area notices that
neither baby is wearing an ankle I.D. band.
She immediately looks on the floor at the foot of each infant warmer and
sees two I.D. bands. She picks the bands
up and places them back on each baby’s ankle.
They are inadvertently placed on the wrong baby. Unfortunately, the wrong mother and baby were
discharged from the hospital.
5) Two babies having the same last
name, or the exact same names are inadvertently transferred to the wrong mother. Only their name was checked and not their I.D.
number.
Prevention:
The mother/baby unit policy should state that anyone
authorized to transport infants, must verify the baby’s I.D. number with the
mothers’. The infant’s I.D. number is
read out-loud to the mother and the mother reads her number back to the nurse
out-loud. Each time a baby is
transferred to or from an infant carrier or crib, the crib card I.D. number
should be read out-loud as well as reading the baby’s I.D. number to verify that
the crib-card number matches the infant I.D. number. The baby’s Infant identification band is to
be put on the infant’s ankle at birth, before the mother and baby leave the
delivery room.
Baby Matching Systems
Ninety-Nine percent of the
time Mother/Baby Mix-Ups happen because of human error. This occurs when a nurse or staff member
accidentally gives the wrong baby to the wrong mother. The weakest link in the
security chain is, and has always been, human error. Depending solely on human accuracy is a
practice fraught with problems. As a
result, several electronic infant protection system manufactures have developed
electronic Mother/Baby Mix-Up protection.
An infant protection and mother matching tag are attached to baby’s
ankle at birth. Each time the baby is
taken to the mother’s room mother/baby matching takes place
electronically. Once the match is
authenticated electronically, the baby is given to the mother. Hospitals that purchase new or replace
existing infant electronic protection systems need to make sure that the
replacement system selected has electronic matching capability. When selecting an infant protection system it
is essential that the system alarms when:
Any system you select should
be designed for self-testing and supervision.
Tag status should be available at any time, and loss of signal or “low
battery” should immediately generate a response. The bracelet material should contain no latex
and be non-allergenic, as well as water-proof to allow infants to be
bathed. The system selected should have
the capability to interface with CCTV cameras, door locks, pagers, and elevators. When an infant comes in close proximity to an
exit door the door should lock automatically and the system should alarm.
One of the most important
features of an infant electron protection system is the support provided by the
manufacturer / vendor. Any system should
also have the capability to expand to provide protection for future growth of
the maternal / child care facility.
CASE STUDY
#1021 HOSPITAL MOTHER / BABY MIX-UP
The victim hospital in Southern California had been consistently below
their staffing requirements for some time and very seldom followed their policy
and procedures during the discharge of their mothers and babies. As a result of lax procedures, the wrong baby
was given to a mother being discharge and she ended up taking the wrong baby
home with her. Immediately, an
investigation was completed by the Department
of Facility Services and the hospital was cited for not following hospital
procedures. The facility was also cited
for chronic understaffing on the maternity unit, and four nurses were charged
with failing to properly match the mother to her baby. Two of the nurses responsible for the
mother/baby mix-up were fired and two others were suspended. Under staffing was listed as the number one
contributing factor to the mother/baby mix-up and the state’s report charged
that the hospital was in violation of nurse-patient staffing rations as
outlined by the American College of
Obstetricians and Gynecologist (ACOG) and the American Academy of Pediatrics (AAP). Documentation showed that on one shift one RN
was responsible for providing care for 16 patients. The hospital stated the citation the hospital
received for failing to report the incident in a timely manner was caused by a
holiday and a three day week-end.
Contributing Factors / Vulnerabilities Unique to this Case
|
· Failing to follow policy
& procedure |
· Quality Control not
established for discharge |
|
· Unacceptable
nurse-patient ratio |
· Failure to report in a
timely manner |
|
· Frequent under staffing |
· Limited Parental
Education |
|
· Inadequate Physical
Security |
· Policy not enforced by
management |
|
|
|
Preventive Measures
1. Provide on-going, in-service education for
all staff on all policies and procedures
2. Develop a policy that requires a second nurse
to verify matching at discharge
3. Require the infant’s I.D. number to be read
out loud by the nurse to the mother
4. Require the mother to read the infant’s I.D.
number to be read back to the mother
5. Evaluate nurse-patient staffing ratios on a
regular basis.
6. Educate parents on their responsibility to assist
in the proper identification of their baby
7. Verify babies in the unit with the same last
name
8. Babies with identical names should have a
special tag that reads “Please verify my Name”.
9. Never carry more than one baby at a time into
a semi-private room.
10. Consider upgrading or replacing your infant
electronic protection system with a mother/baby mix-up protection and alarm.
NOTE: Consult with a Healthcare Security
Professional with expertise in infant and pediatric security to assist you and
your staff in developing the most effective and cost efficient security program
for your facility. In most cases, a
security professional can save the hospital considerably more money than would
be spent on the consultant’s fee. SAI has written an educational pamphlet – “Infant
Security – How Parents Can Help” designed to assist hospitals in
educating new mothers and their families, and meet Joint Commission
requirements.
http://www.saione.com/mixups.htm
Baby Mix-Up At Norton Hospital
-
http://www.saione.com/Baby_Mixup_at_Norton_Hospital.pdf
Hospital baby mix-up
renews old fears - By Stephen Smith, Boston Globe Staff
http://www.saione.com/hospital_baby_mix_up_renews_old_fears.pdf
Preview: "Baby Swap" - a NewsPronet Interactive Special Report produced by SweepsFeed
http://www.saione.com/13930-BabySwap.wmv
On-line resources
The Case for Mother / Infant Matching
http://www.xmarksystems.com/pdfs/hugs_news_q2_2004.pdf
Media Interview Q & A with
Jeff Aldridge, CPP
http://www.saione.com/mediainterview.htm
Litigation Avoidance
Fallacy of Foot Printing – Is
Foot printing a "thing of the past?”
Educating Employees and Staff
“Pros & Cons of an Infant
Protection System”
Disclaimer
Advice given in this "Newsletter" is
general in nature, and subscribers (readers of this material) should consult
with professional counsel for specific legal, ethical, or clinical advice. The information
provided in the SAI Newsletters is for educational purposes only and
should not be considered 'legal' advice. Websites listed are for
reference only and are provided for subscribers (readers of the material) to
have an opportunity to read the original documents in total. Please
consult your legal counsel or Compliance Officer for clarification of laws and
rules related to your State when applicable.
SAI
is not affiliated with the Joint Commission on Accreditation of Healthcare
Organizations.
SAI - ©January, 2005