The Baby Mix Up

About a month ago, a close relative of mine (we’ll call her Samantha) had a baby girl (we’ll call her Christina). Both mom and baby handled the delivery well and were recovering happily in the maternity ward at the hospital. Samantha had decided, along with her husband, that they were going to breastfeed Christina, a relatively insignificant decision in most instances, but one that would come into play during their second night at the hospital.

During the night, while Samantha was sleeping in her room and Christina was sleeping in the nursery, one of the nurses got Christina, brought her into the recovery room, checked the ankle band on baby and mom, and left the room. Mom held the baby for a bit, got a bottle ready, and started to feed her…that’s right, got a bottle ready for a breast-fed baby! It seems the nurse’s aged eyes mistook the last number on Christina’s ankle band (an 8) for the same last number on a different mom’s wristband (a 0), after somehow mistakenly taking Christina into the wrong room!

Samantha and her husband weren’t all that concerned that Christina had received a little bit of formula (probably less than an ounce), which really was the extent of the damage caused by the mix up, as the other mom quickly came to realize that she wasn’t feeding her own baby. But as the father of two young children, I can only imagine how scared, shocked, confused, and down-right pissed off both sets of parents must have been when they learned what had happened.

Those first few days that a mother spends with her baby in the hospital are a crucial bonding time; can you imagine looking down as you feed a baby and realize it’s not yours? The questions that must have gone through her head must’ve been numerous: “Where’s my baby?” “Is someone else breastfeeding her?” “Whose baby is this?” “How did she end up in my room?” “How could the nurse not know she wasn’t my baby?”

Or can you imagine being awoken in the middle of the night by hospital staff to be told that your newborn was just brought to the wrong room, held by the wrong mom, and fed in the wrong manner, all at a time that’s emotional enough for new parents? I certainly can’t! Further, what if Samantha and her husband were firmly against formula feeding?

And trying to grasp the answers to these questions is the least of the issue here. What if Christina had been brought to the wrong mom right before being released to go home? How long would it have been before the mix-up was realized? How long would the other mom’s baby have sat alone in the nursery? How long would Samantha have sat in her recovery room wondering where the hell her baby was?

All of this could’ve been avoided if the current standard at most hospitals wasn’t to rely on visual confirmation of ridiculously small text, which frankly isn’t carried out every time the baby is transferred between the nursery and the mother’s room—in my experience and that of my friends and family. Sure, many hospitals also attach an alarm to baby’s ankles to make sure they aren’t taken from the nursery without being with the right parents. But this assumes that the right baby is with the right parents when that alarm is taken off just prior to release from the hospital.

Could this alarm system not be adapted to verify when a baby has been brought to the correct mother’s room? The same sensors used on the exit doors could be installed at the doors over every mother’s room, perhaps signaling a single beep when the baby is entering the right room and sounding alarm or causing a flashing light on the ankle alarm when not.

What about a digital system using bar codes? It’s already widely used for prescriptions administered in the hospital. The nurse could scan the baby’s ankle and then the mom’s right before leaving the baby in the mom’s recovery room. Or a scanner could be installed in the doorway—having been set to read the same number on both the mother’s and baby’s bands—that would scan the band when the baby is brought to and from the room, and also to and from the nursery, keeping track of his or her whereabouts and alerting staff when a baby has been released from the nursery but not brought into the mother’s room for a given time (say, two minutes).

Now, the prices and creation of these solutions is certainly beyond my grasp. I’ll leave that up to the HIT vendors and hospital administrators to advance upon the few already-issued patents for a "Infant and parent matching and security system and method of matching infant and parent" and "Systems and methods for tagging and identification"—I guess I’m not alone in my thinking. But I’m counting on you, the practicing healthcare professional, to help get the point across that a HIT solution is needed to avoid such potentially serious—not to mention lawsuit-inducing—situations.

As always, I welcome your comments. Thanks for reading!