Parent Misidentification Leading to the Breastfeeding of the Wrong Baby in a Neonatal Intensive Care Unit

Abstract

Patient: Male, 2 monthFinal Diagnosis: 2 month old 32 weeks’ gestational age preterm infantSymptoms: PrematurityMedication: —Clinical Procedure: Accidental breastfeeding of the wrong babySpecialty: Pediatrics and NeonatologyObjective:Diagnostic/therapeutic accidentsBackground:Because there are clear benefits to breast milk over formula for infants, the goal of the World Health Organization is to increase breastfeeding rates. As more women are breastfeeding and providing breast milk to newborns in hospitals, there is increased risk for administration error.Case Report:A hospitalized preterm infant was breastfed by the wrong mother when the Neonatal Intensive Care Unit Nurse failed to properly identify the mother. An infectious disease workup done on the donor mother was negative, but the recipient infant was positive for cytomegalovirus (CMV). Since the donor mother who accidentally breastfed the wrong infant was CMV-negative, the baby in our case had likely been exposed to CMV from his biological mother. The attending physician apologized to all of the family members involved, but the father of one infant continued to express anger.Conclusions:To our knowledge, this is the first case of accidental breastfeeding in a hospital setting to be described in the literature. Parental misidentification and a language barrier led to the error. An infectious disease workup did not find any evidence of disease transmission from this event. Increased attention to minimize breast milk errors is needed. Despite a long history of wet nursing, unregulated breast milk sharing and cross nursing is not recommended. Instead, if a mother cannot provide breast milk herself, pasteurized donor breast milk from breast milk banks is encouraged.

Realidade do aleitamento materno cruzado em Maternidade Filantrópica de Aracaju, Sergipe

“…O leite materno pode transmitir doenças conhecidas e desconhecidas e por isso, quando se é doado ou compartilhado, ele deve ser pasteurizado antes de ser dado à criança. O número de UTINS que utilizam o leite materno pasteurizado das doadoras dos bancos de leites aumentou nos últimos anos, porém muitas instituições ainda não adotaram essa medida seja por questões de custo, falta de disponibilidade, resistência dos pais em aceitar o leite doado, questões culturais, religiosas ou legais (Sauer et al, 2016).…”

Application of Human Factors Methods to Ensure Appropriate Infant Identification and Abduction Prevention Within the Hospital Setting

“…5 Although the risk of infant misidentification ranges from 20.6% to 72.9% for average daily census, 6 the risk for misidentification is not just limited to being sent home with the incorrect mother/parents but also to being provided incorrect medications/breast milk or being given the wrong infant to breastfeed. [6][7][8][9] When analyzing infant security systems, teams must also consider the potential that security measures may induce unnecessary fear or anxiety in new mothers and family members. Analyzing the security processes surrounding infant identification and abduction prevention can provide valuable insight into the potentials for failure as well as the areas where patient perception is different from the presented realities.…”

Addressing the identity crisis in healthcare: positive patient identification technology reduces wrong patient events

“…In 1953, Byrne reported that 12% of medication administration errors were “medication given to the wrong patient.” Our willingness to publish wrong patient errors suggests a readiness to learn from our mistakes and change the system within which we work. Previous articles have reported the wrong patient undergoing an invasive cardiac electrophysiologic study despite her attempts at refusal, an inadvertent HLA‐incompatible allogeneic bone marrow transplant from the incorrect donor, the wrong infant breastfed in the neonatal intensive care unit after a bed move, and using the wrong ABO group red blood cells (RBCs) to prime the bypass circuit for an infant undergoing congenital heart surgery …”

“…Our willingness to publish wrong patient errors suggests a readiness to learn from our mistakes and change the system within which we work. Previous articles have reported the wrong patient undergoing an invasive cardiac electrophysiologic study despite her attempts at refusal, 4 an inadvertent HLAincompatible allogeneic bone marrow transplant from the incorrect donor, 5 the wrong infant breastfed in the neonatal intensive care unit after a bed move, 6 and using the wrong ABO group red blood cells (RBCs) to prime the bypass circuit for an infant undergoing congenital heart surgery. 7 Despite health care leaders recognizing this "identity crisis," we continue to have unacceptable failures in patient identification leading to transfusion of ABO-incompatible blood, incorrect laboratory results, 8 incorrect anatomical pathology specimens, 9 incorrect diagnostic imaging, 10 incorrect surgical procedures, 11 unnecessary delays, patient anxiety, need for sample re-collection, wrong medication administered, unnecessary radiation exposure, wrong breast milk administered, and wrong infant sent home with parents.…”