What’s New in the Patient Safety World

September 2011

Another Breastfeeding Mixup



In our November 17, 2009 Patient Safety Tip of the Week “Switched Babies” we did a fairly extensive review of the problem of the wrong babies being given to the wrong mothers. The exact incidence of this problem is unknown but in doing our research we found an article in the news about such switches occurring somewhere almost every year. Now another episode has occurred in Australia (Cooper 2011).


In the recent Australian case, the two switched babies spent about 8 hours with the wrong mothers. Both were breastfed during the period with the wrong mothers so testing for potentially transmissible pathogens must be done. Details of the hospital’s investigation are sparse but apparently there was failure to verify identities on the bracelets.


We’ve done FMEA’s (Failure Mode and Effects Analysis) on this potential issue in the past and no matter how safe you think your present system is your FMEA will likely uncover potential vulnerabilities.


See our November 17, 2009 Patient Safety Tip of the Week “Switched Babies” for an extensive discussion of the risk factors and contributory factors to incidents of both switched babies and breastmilk mixups.




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







Cooper A. Switch shock as newborns go to wrong families. Sydney Morning Herald. July 18, 2011















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