Patient Safety Tip of the Week


November 17, 2009        Switched Babies


Here’s a topic where we really are asking our readers for their input and opinions. Mercy Medical Center in Williston, North Dakota had an incident this past September in which the wrong baby was given to a mother at discharge. The error was recognized within hours and both babies were reunited with their correct mothers promptly. Last week Mercy Medical held a press conference in which they transparently disclosed the details of the incident (maintaining patient confidentiality, of course) and the results of the subsequent root cause analysis (RCA). We applaud Mercy Medical for their actions. Not only do their actions bring credibility to themselves but they also raise the issue for all other hospitals to address. We challenge each and every hospital to honestly answer the question “Could that have happened here?”. Most will probably say “I really don’t know. Certainly the human error element could happen here. But I’m not sure if our safety net and safety systems would prevent the actual adverse outcome.”


Sending a baby home with the wrong parents is the worst case scenario but in-hospital baby mixups, which are probably more common, can be just as traumatic. Not only are they psychologically devastating for many parents but the issue of potential infection transmission is raised when babies are breastfed by the wrong mothers.


Mercy Medical’s actions after their root cause analysis include reenforcement of some current policies and simplification of others. They also developed a tracking log in which the hospital staff logs each baby's movement after the child is taken from a bassinet for changing and feeding. And the discharge process was changed so that babies are not allowed to leave the hospital until a wristband is double-checked against paperwork.


Statistics on the frequency with which such misidentification errors result in actual baby switches are not readily available. From time to time one hears a story about adults who find out they were switched as babies many years earlier. But there are few stories about such baby switches at the time they actually occur. In 2008 there was such an occurrence at a southern Illinois hospital. In that incident the mixup apparently occurred when two babies were sent to the OR for circumcisions. We are unaware of publication of the root cause analysis from that hospital or from The Joint Commission, which investigated the incident, but a subsequent lawsuit alleged that the personal identification materials had been removed for the surgery and the mixup apparently occurred when they were reapplied.


After an incident in Queensland (Australia), which requires reporting of such events regardless of ultimate outcome, was made public it was revealed that there had been 57 cases in which at least one identification tag of an infant was missing or contained the wrong name in 2008, and 55 cases in 2007, though no infants went home with the wrong family. But there were cases where the wrong infant was breastfed by the wrong mother, necessitating testing for hepatitis and HIV. Even then, we know that even in mandatory incident reporting systems there is significant underreporting.


If you google using enough search terms, you can find about a case a year that appears in newspapers worldwide.


For at least the last 10 years, most hospitals have had fairly sophisticated systems in place to avoid infant abductions and to respond prompty if one occurs. The Joint Commission issued a Sentinel Event Alert in 1999 that identified root causes in cases of infant abductions from hospitals and made numerous recommendations for steps to prevent such. All hospitals have developed infant abduction policies (often called “Code Pink” policies). Among those recommendations were attaching secure identically numbered identification bands to the baby (wrist and ankle bands), mother, and father or significant other immediately after birth. In addition, the footprint of the infant and a color photograph of the infant are recommended. Some hospitals also use a fingerprint of the mother in the identification process. Prompt recording of the physical examination of the infant is also useful in the identification process (eg. recording of birthmarks may be very helpful in correct identification). Code Pink policies also include conspicuous identification badges for all staff members, good security/surveillance of all access and exit sites, and high tech infant security tags and alarm systems. Note also that you may wish to modify your Code Pink policy to also include patients who have eloped or are otherwise missing (see our July 28, 2009 Patient Safety Tip of the Week Wandering, Elopements, and Missing Patients). So many elements of your Code Pink policy should also be helpful in preventing baby mixups.


Education of both staff and the family are important in preventing infant abductions but should also be extended to help prevent incorrect identification of infants. When providing such education to mothers and family, it is important to assess their level of understanding. It may actually be wise to do that education twice with the mother, once in the days or weeks just prior to anticipated delivery and then again immediately after delivery when the ID tags are being placed. You need to keep in mind that the mother’s cognition may be impaired by drugs used during labor and delivery and she may not fully comprehend what she is being told at that time. In any case, the identification process should be reinforced on every interaction between mother and baby and staff.


The following may be contributing factors in some cases of baby mixups:

·        Understaffing/excess workloads

·        Change of shift or change of personnel

·        Babies often born about the same time

·        Babies may often go for feeding about the same time

·        Babies may often go to the OR for circumcision about the same time

·        Preparing more than one patient identification tag at a time

·        Mother is not yet familiar with the baby (may have only seen him/her once!)

·        Similar names


Some contributing factors gleaned from the scant literature on baby mixups appear to be understaffing or excessive workload and also change of shift. Several of the events have occurred when the person applying the identification tags is different from the  individual immediately responsible for the infant at delivery.


Maternal recognition of the baby is an issue. We’ve heard people say “How could that happen? Couldn’t the mother recognize she had the wrong baby when she left the hospital?”. Well, think about that. The time of greatest risk for such misidentification is when the ID tags are first being affixed. The mother probably only sees the baby briefly at delivery and could not be expected to recognize that baby based on that sole exposure (particularly if drugs had to be used during labor and delivery). When the baby is later brought back for breastfeeding or just bonding, the mother then begins to recognize that baby as her baby (and the mixup may have already occurred!).


The use of two identification bands on the baby, however, is also not an infallible method of identification. In a baby mixup in a Hong Kong hospital this year, two babies had different identification bracelets on their wrists and ankles. Each was breastfed by the wrong mother for several days before the mixup was correctly sorted out using birthweights, footprints, blood typing, and eventually DNA identification.


The root cause analysis of the Hong Kong incident is very instructive and confirms some of the factors that increase the risk of such infant misidentifications. That incident was only recognized when the mother of one baby let the nursing staff know that the wrist band of her baby was missing but there was a wrist band bearing the name of another mother in her baby’s cot (subsequent DNA testing confirmed the mixup).


That hospital had what sounded like good policies and protocols in place for proper identification of newborns. But one nurse prepared the ankle bracelets for two babies at the same time and asked a ward assistant to affix them to the ankles of the respective babies. That assistant checked the information on the ankle bracelets with that on the head of the cots but not against the babies’ wrist bracelets. And the nurse did not verify with the mothers the baby identification at time of first feeding. There were other system issues as well, such as inadequate systems to ensure staff at all levels were apprised of updates to policies and procedures and lack of a good system for monitoring compliance with key elements of the policies.


We have previously identified that doing things on two (or more) patients at the same time raises significant patient safety issues. See our Patient Safety Tips of the Week for June 19, 2007 “Unintended Consequences of Technological Solutions” in which we described inadvertent transposition of remote telemetry units when 2 units were prepared at the same time and April 23, 2007 “Predictable Errors” in which we describe the “two in a box” type of error. Multitasking may be good for some things but, frankly, it is dangerous for most things we do in healthcare.


Similar names is always an issue when it comes to wrong patient events. In our May 20, 2008 Patient Safety Tip of the Week “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?” we noted you would be surprised to see how often patients with the same or very similar names may be hospitalized at the same time. Shojania (2003) described a near-miss related to patients having the same last name and noted that a survey on his medical service over a 3-month period showed patients with the same last names on 28% of the days. The problem is even more significant on neonatal units, where multiple births often lead to many patients with the same last name being hospitalized at the same time and medical record numbers being similar except for one digit. Gray et al (2006) found multiple patients with the same last names on 34% of all NICU days during a full calendar year, and similar sounding names on 9.7% of days. When similar-appearing medical records numbers were also included, not a single day occurred where there was no risk for patient misidentification. Both these studies were on relatively small services so one can anticipate that the risks of similar names is much higher when the entire hospitalized patient population is in the database.


In addition to mothers directly breastfeeding the wrong baby, there is the risk of babies being fed expressed breast milk from the wrong mother. The Pennsylvania Patient Safety Authority issued a Patient Safety Advisory on Mismanagement of Expressed Breast Milk in 2007. The Pennsylvania Patient Safety Reporting System (PA-PSRS) had received 20 reports of infants being fed another mother’s expressed breast milk. They identified risk factors that involved not only identification issues but also labeling issues, and problems with verification, storage and dispensing. The Advisory has good recommendations on risk reduction strategies and an excellent section on how to respond and manage patients when such exposures do occur, particularly managing the risk for infectious disease transmission. All those recommendations obviously would also apply in cases where infants were directly exposed to breasfeeding by the wrong mother.



Certainly, a number of patient safety tools are available that might reduce the chance of baby mixups. These include both high tech and low tech tools. Barcoding is an obvious tool, given that so many hospitals have now moved to barcoding systems to improve medication safety. The design of the identification bracelets for babies and parents are beyond the scope of this column but the issues can get quite complex. Barcoding can be either linear or 2-dimensional and the number of elements staff want to display on barcoded identification bracelets can get quite cumbersome. Design of the bracelets and labels for the infant is also tricky, given the small wrists and ankles the babies have and the problem that the resulting curvature makes scanning more difficult. The actual unique identification code that appears on both the baby’s and mother’s bracelet needs to be something other than the medical record number. Otherwise you would increase the risk of administering a drug to the mother instead of the baby or vice versa. And, though barcoding is a great tool, it doesn’t help if the bracelets/labels were already mixed up and it can often give rise to a false sense of security.


So back to low tech! The timeout is a logical tool to use. Just as in the OR we use a timeout to verify the correct patient (and many other things) you could use a timeout to verify the correct baby/mother combination or identify the correct baby going for any other procedure. Use of checklists could also be very valuable. We haven’t seen the tracking log that Mercy Medical described in its corrective actions but a tracking log could easily be designed in a checklist format that would include appropriate reminders for patient identification and baby/mother verification. We’ll bet some obstetrical units or nurseries or NICU’s could get creative and develop a Ticket to Ride type tool (see our November 18, 2008 Patient Safety Tip of the Week “Ticket to Ride: Checklist, Form, or Decision Scorecard?”).


What about double checks? A point we have made over and over is that double checks are very weak safety interventions. From all industries we know that the error rate when a supervisor checks someone else’s work may be 10% or higher. And we don’t know what influence the double check has on the error rates of the original person. It is quite conceivable that the original person may make more errors if they feel that their errors will be intercepted by a second reviewer. We have certainly seen in some technology solutions that staff become so confident in the computer’s ability to capture errors that their own vigilance may wane. Nevertheless, the literature supports a medication error reduction of about 30% when using a double check system. So one might anticipate some potential benefit if double checks, such as at discharge, were applied to the baby/mother identification verification process.


And, importantly, we feel that you must have some way of auditing your processes to ensure compliance with your well-intentioned policies. The best policies in the world will not help if no one adheres to them. Plus auditing helps you identify when workarounds are being used. Workarounds are almost always indicative of a flaw in your policy or procedure and should tip you off that you need to fix the underlying system. The audits could be random spot audits or “secret shopper” type audits.


It also seems to us that the complexity of the identification process and some of the reduncancies built into it may actually be contributing factors to some cases of misidentification. Having 3 identification tags (wrist band, ankle bracelet, and bassinette tag) rather than 2 increases the mathematical possibility there will be mismatches of tags. We understand that the tags often fall off babies or may become illegible due to moisture, etc. so we understand the rationale for using 2 tags on the babies. But if (as seen in the Hong Kong case RCA) everyone focuses on only one of the tags and largely ignores the  other, are we just adding to the complexity?



So how do you prevent such mixups from happening at your facility? Are you at risk? This is another great topic for your organization to perform a FMEA (failure mode and effects analysis) on. We’d be interested in hearing what you find!




Update: See our December 11, 2012 Patient Safety Tip of the Week “Breastfeeding Mixup Again”.







Smith N. Mercy officials explain switched babies. Officials say human error was the reason for the mistake.
Williston Herald. November 11, 2009



Families sue over infant switch.

John D. Homan, April 11, 2008



Queensland hospital errors lead to newborn mix-ups

Patrick Lion  April 17, 2009,23739,25348095-952,00.html



The Joint Commission. Sentinel Event Alert. Infant Abductions: Preventing Future Occurrences. Issue 9 April 9, 1999



Breast-feeding error adds to mix-up moms' miseries.
Two registered nurses and a health assistant have been sent for retraining and placed under supervision following a mix-up in which two mothers breast-fed each other's baby for at least 36 hours.
Patsy Moy and Andrea Chan
The Standard (China) Tuesday, August 18, 2009



Investigation Report of the Incident with Misidentification of Two Babies in Queen Elizabeth Hospital



Shojania KG. AHRQ Web M&M Case and Commentary. Patient Mix-Up. February 2003.



Gray JE, Suresh G, Ursprung R, Edwards WH, Nickerson J, Shiono PH, Plsek P, Goldmann DA, Horbar J. Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 2006;117;e43-e47



Mismanagement of Expressed Breast Milk

PA PSRS Patient Saf Advis 2007 Jun;4(2):46-50













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