Best Practice: Mother/Baby Safety Bundle, Mother Child Unit
The Valley Hospital, Ridgewood, NJ
An unthinkable event occurred on the Mother Baby unit at The Valley Hospital, Ridgewood, NJ. An infant was misidentified and given to the wrong mother to feed. The nursing staff was devastated. They questioned how this could happen when Mother Baby nurses are so diligent about checking identification bands. The shared governance team took up the issue to dissect and explore potential solutions.
Our shared governance team looked at the processes that surround the identification of infants. We relied heavily on hand-printed baby bands and a verbal reading of an identification number to properly hand off our babies to parents or support people. Turning to the literature, the prevailing best practice indicated some sort of technology to provide an additional layer of security; however, recommendations for specific products or types of technology were lacking.
Our team reached out to other hospitals nationally and evaluated products available for purchase. Most products were costly or involved a large renovation of our infrastructure or IT system. The chair of the shared governance council, Erica Scalise, BSN, RNC-MNN, collaborated with our nurse informaticist, Lauren Piech, MPH, RN-BC, to explore what capabilities our current IT system could provide. Bar code technology had recently been implemented for medications and breast milk, so Erica and Lauren explored its application for correctly matching a baby to its mother. After beta testing and multiple prototypes for identification bands, a small bar code band was created that loops within an infant’s existing ID band to provide the additional layer of protection we desired to identify babies.
Thanks to the work of Erica and Lauren, and the shared governance team members who successfully implemented the process, we have been scanning all our infant hand-offs (approximately 2,300 scanning occurrences per month). No infant mismatches have recurred.