The Valley Hospital shared governance team developed an innovative barcode-based infant identification system to prevent baby mismatches on the Mother Baby unit.

Best Practice: Mother/Baby Safety Bundle, Mother Child Unit, The Valley Hospital, Ridgewood, NJ

Erica Scalise, BSN, RNC-MNN, is the chair of the shared governance council and Lauren Piech, MPH, RN-BC, is the nurse informaticist at 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. In response, the shared governance team took up the issue to dissect and explore potential solutions.

The team began by examining the processes surrounding infant identification. Previously, they relied heavily on hand-printed baby bands and a verbal reading of an identification number to properly hand off babies to parents or support people. After 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.

As a next step, the team reached out to other hospitals nationally and evaluated products available for purchase. Most products were costly or involved a large renovation of the infrastructure or IT system. To find a better solution, the chair of the shared governance council, Erica Scalise, BSN, RNC-MNN, collaborated with nurse informaticist Lauren Piech, MPH, RN-BC, to explore what capabilities the 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, they created a small bar code band that loops within an infant’s existing ID band to provide the additional layer of protection desired.

Thanks to the work of Erica and Lauren, along with the shared governance team members who successfully implemented the process, the unit now scans all infant hand-offs (approximately 2,300 scanning occurrences per month). As a result, no infant mismatches have recurred.