Report: Pa. hospital mixups meant babies got wrong breast milk, treatments

New parents: Did the hospital temporarily label your newborn with the first name of "Babyboy" or "Babygirl"?

If so, double-check the label when nurses give you a bottle of breast milk. There is a small chance that the milk came from another mother.

A new study by the Pennsylvania Patient Safety Authority found 1,234 misidentification "events" involving babies born at hospitals and birthing centers in the state in 2014 and 2015, averaging about two a day.

In almost all cases, there was no harm to the baby, generally because providers caught the mistake before it led to any incorrect treatment. But in five cases, a newborn experienced harm, according to the study by the state agency. These included several instances of a baby receiving a bottle of breast milk that came from another mother, and one case of a circumcision being performed without the parents' consent.

In keeping with state law, the report did not identify any hospitals by name, nor did it specify the nature of the harm involving breast milk.

Ordinarily, milk from a different mother would not cause harm, though there is a small chance of transmitting an infectious disease, said Katja Pigur, director of breastfeeding services at the Maternity Care Coalition, a Philadelphia nonprofit that focuses on maternal and child health.

Given the infrequency of wrong-baby events to begin with, she said, the chance of any disease transmission from a mother to someone else's baby is low.

"I think this is a very rare occasion that that would happen," Pigur said.

Hospitals generally keep the baby with the mother as much of the time as possible, but errors are more likely to arise with newborns who must spend time in the intensive care unit, the report suggests.

Nearly three-fourths of the 1,234 events involved procedural errors, such as mislabeled blood specimens, unlabeled urine samples, and X-rays being ordered for the wrong patient (but caught in time).

An additional 10 percent of the events involved general misidentification errors, such as mismatched ID bracelets on the mother and child and "transferring issues such as the wrong newborn taken to the parents," the report stated.

The report found 89 cases of breast milk administration "mishaps" during the two-year period, including cases in which babies got milk from a different mother. Authors also identified 110 medication events, including giving the wrong drug to a patient, though most errors were caught in time. For instance, one pharmacist noticed that a baby's weight did not match what was on a prescription order and flagged the problem to caregivers.

No babies went home with the wrong parents.

Michael J. Consuelos, senior vice president for clinical integration at the Hospital and Healthsystem Association of Pennsylvania, said hospitals in the state take lots of steps to avoid errors.

These include promptly giving them their own electronic health records and using bar codes for unique identification.

"Hospitals strive to eliminate every possible source of patient harm, and the report suggests that newborn identify checks and double-checks are catching almost all identification problems before they impact patient care," Consuelos said.

Authors of the report suggested a variety of preventive measures, many of them already common:

Rather than identify a baby as "Babygirl Jackson," hospitals should use temporary first names based on the mother's first name, such as "Wendysgirl Jackson," to avoid confusion if there are multiple babies with similar last names.

Place newborns with similar last names in a different pod.

Use ID bracelets with unique identifier technology, such as bar codes or radiofrequency tags.

Apply such bracelets to two sites, such as wrist and ankle.

Check multiple identifiers before entering information into the patient's medical record. 215-854-2430 @TomAvril1