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C'EST ARRIVÉ

articles de journaux, usa

C'EST ARRIVE
Quelques chiffres sur la substitution d'enfants
Substitution d'enfants à Roubaix,1957
Adoption illegale
Adoption ou rapt d'enfant...?
Perte d'identité au passage des frontières
DANS LE MONDE, CAS RESOLUS
DES SOLUTIONS...?
FAITS/FACTS

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“Recent Media Headlines”

 

 

Parents sue hospital

in mix-up of babies

Hospital in baby mix-up

Short on Nurses

Tests Show Virginia Babies Were Switched

Infant Switched

at Hospital

Parents Sent Home

 With Wrong Baby

Swapped Babies, Shattered Families

 

Hospital Baby Mix-Up Renews Old Fears

 

Nurse fired after babies 'swapped'

Mother wary of AIDS

to sue hospital after mix-up

 

Hospital sued over 45 min baby switch – Los Angeles Daily News

Report details frequent understaffing in St. Joseph Hospital – Nurseweek/Healthweek

 

 

 

A new mother was given wrong baby to nurse at Lowell General Hospital - Lowell, Mass (AP)

 

 

Switched Baby’s Mom Sues Hospital

Police report says babies switched

when ID bracelets loose or missing

Loose or missing ID bracelets led to baby-switch,

nurse error cited.

 

                                                                                                      

                    

 

 

State investigating hospital in baby mix-up.  Hospital in mix-up short on nurses.

Nurse Error Cited in Baby Switch


 

 

Infant Security News

Dedicated to Preventing Infant Abductions & Mother / Baby Mix-ups

 

 

Security Assessments International  2405 Monthaven Drive, Durham, NC  27712  (919) 384-8299

Safety, Security & Risk Management Consultants

Routing:  [ ] Facility Services   [ ] Security Management   [ ] Nursing Administration   [ ] Risk Management

 

 

VOLUME III                                     NUMBER I                                        January, 2005

 

 

“Infant Security News” is SAI’s quarterly newsletter dedicated to helping hospitals protect their youngest patients.  Each edition of this free newsletter will feature current infant security events in the news, and each issue will analyze an actual infant abduction or mother/baby mix-up case.  Cases are assessed to determine how security was defeated and preventive measures recommended to prevent future occurrences.

 

 

 

PREVENTING MOTHER/BABY MIX-UPS

(Best Practices)

 

The following information is designed to assist individual hospitals in preventing mother/baby mix-ups through staff awareness, education and best practices.

 

 

MOTHER/BABY MIX-UPS 

by Jeff Aldridge, CPP

 

 

The happiest time in a new mother’s life is the anticipated delivery of her new baby.  Her greatest fear is that something will happen before she and her new bundle of joy can return home safely.  There is no way to describe the absolute horror parents go through when they discover the baby that they have taken home is not theirs.  So you may ask… how in the world can such a thing happen?  And what can hospitals do to prevent such a devastating event?

 

Of the 4.2 million live births in the U.S. annually, approximately 3.9 million are born in acute care hospitals.  A mother and baby’s average hospital stay is around 24 hours for normal births and 72 hours for complicated births or C-Sections. This means that infants are transferred to and from their mothers in the hospital an estimated 23 million times each year.  Based on a study conducted by a research group there are over 23,400 erroneous infant to mother transfers annually.  That translates to 64 mother/baby mix-ups a day, or 2.7 mix-ups an hour.  Fortunately, the vast majority of these switches are caught before the baby is taken home.

 

Mother/Baby Mix-Ups

 

“Hospital administrators attribute the mix-up of a baby, given to the wrong mother, as simply ‘human error’.  When this type of event occurs, the hospital pledges to immediately adopt more safeguards to prevent such mistakes from happening in the future”.

 

 

“A state investigator finds that the placement of an infant with the wrong mother was the result of human error stemming from the nurse misreading the mother and baby’s ID band”.

 

 

“It’s every mother and father’s worst nightmare… parents of a newborn discover their baby has been given to another mother and sent home with the wrong parents.  The accidental switch was discovered when the parents realized their wristbands did not match the one on the baby’s ankle they brought home from the hospital.  The baby was immediately returned to the rightful parents.  Hospital pleads “Human Error” and promised it will never happen again.”

 

 

“A new mother, who accidentally breast-fed another mother’s baby, discovered that she had nursed the wrong baby and that the baby was HIV positive.  The victim mother plans to sue the hospital responsible for the mother/baby mix-up.  The mother of the other baby tested positive for the human immunodeficiency virus which causes AIDS.

 

 

One of the most publicized cases of a mother/baby mix-up occurred at the University of Virginia Medical Center in 1995.  According to one news report, Rebecca Chittum and Callie Marie Conley apparently experienced problems with their ID bands just prior to being discharged.  No evidence was discovered to show that the mother/baby mix-up was intentional.  Three years would pass before the mix-up would be discovered by the parents.  Paula Johnson, mother of one of the babies said too much time had passed for any of the staff to recall exactly what had happened.  She learned that nurses “routinely” misplaced ID bands.  At the time of discharge a parent noticed that one of the baby’s bands was missing and the other baby’s band was loosely attached to the baby’s ankle. 

___________________________________________________________________________

 

How do mother/baby mix-ups occur?

 

The majority of mother/baby mix-ups occur when a hospital staff member fails to match the baby’s identification number with the mothers’.  This tragic event occurs in thousands of hospitals throughout the U.S. each year.  If used correctly, the infant banding process is designed to prevent mother/baby mix-ups during the routine transfer of newborns.  Each year millions of babies are transported from the mother’s room to the nursery to be weighed, bathed, or medically treated.  Each time a baby is transferred the staff member making the transfer is required to verify the infants I.D. number with an identical number located on the mother’s arm band.  This is essential to ensure that the mother receives the right baby. The most critical transfer of all occurs at discharge when the baby is taken from the hospital to the home.  Due to excessive workloads, stress, time constrains, and under staffing, thousands of babies are given to the wrong mothers each year because their identification numbers are not matched to the mother.   This unintentional action is described by hospital administrators as human error.  Here are some of the contributing factors that can lead to a mother/baby mix-up.

 

“Loose ankle band” or “wrist band”

 

An infant I.D. Band slips off of an infant’s wrist and is accidentally placed on another infant’s ankle.

 

 

Cause:

 

When an Infant is delivered in Labor & Delivery the baby’s identification band is securely attached to the infant’s ankle.  After the baby has been transported to the nursery it begins to lose water retained at birth.  Over the next few hours the ankle begins to shrink, because of water loss.   As a result the infant’s identification band becomes lose and slips off the infant’s foot.  Many Infant bands are not adjustable; they use holes in the band are for securing the band to the infant.  This type of infant band should not be used.  Once the band is attached and locked into place, the band cannot be tightened. 

 

Prevention:

 

An ID band that not only locks, but can also be tightened, should be used for infant identification.  It should be placed on the ankle, not the wrist.  One hospital changed their practice of placing the band on the infant’s wrist after a band slipped off the baby’s wrist causing the baby to be given to the wrong mother.  A new procedure was implemented which required nurses to place the bracelet on each ankle of the baby, instead of one on the ankle and one on the baby’s wrist.  Infant I.D. bands should not be place on the infant’s wrist.  Place the second band on the baby’s other ankle.  A policy should be developed that requires staff to constantly check the infant’s band for tautness any time the baby is picked-up or moved.  If your hospital is considering an Electronic Infant Alarms System, make sure the system also comes with a mother/baby mix-up alarm feature. 

 

 

“Unacceptable Nurse/Patient Ratio” 

 

 

Cause:

 

A National nursing shortage continues to adversely affect the hospital’s maternity and pediatric units forcing hospital staff to work with unsafe nurse-patient staffing ratios.  An investigation of one hospital discovered that the mother/baby unit nurse-patient staffing ratio was a contributing factor to a mother/baby mix-up.  The investigation of this particular hospital revealed that on one shift a single nurse was responsible for 16 patients.  The hospital initiated a new policy which requires a second nurse to verify the baby’s identification number matched the mothers’ before the baby is allowed to take her baby home by the mother.  A ‘Best Practices’ solution would have hospitals follow the staffing standard for maternity and pediatric units established by the American Academy of Pediatrics (AAP).

 

Prevention:

 

Infant / Mother Matching has to be verified before the baby can safely be handed over to the mother.  This can be accomplished in one of two ways; by human verification, or by electronic verification.  The human element requires that adequate staffing is always available and staff are always appropriately educated and trained to follow protocols, policies, and procedures.  Today’s state-of-the-art Infant Electronic Protection can protect babies both from abduction and mother/baby mix-ups.  If nurse-patient staffing ratios cannot be met, electronic verification is essential. 

 

 

 

“Failing to follow policies and procedures”

 

Before an infant transfer can be completed the person making the transfer must make absolutely sure that the baby’s identification number matches the mother’s.  Both the mother’s I.D. number and the baby’s should be the same.  Mother/baby mix-ups occur when the baby’s I.D. number is not matched to the mothers’, or the numbers are incorrectly matched.  Babies are placed in harms way when employees and staff fail to follow policy or are absent-minded or inattentive to detail.

 

Causes / Examples:

 

1)      A nurse pushes the mother’s baby into the room in a bassinet, but fails to verify the infant I.D. band with the mother because the mother is asleep.  The mother receives the wrong baby. 

2)      Another nurse enters the mother’s room, reads the infant’s I.D. number to the mother and has the mother check her band, but she or he does not require the mother to read back the number on her band for verification.  The room may be dimly lit and the mother may still be under the influence of medication that was given during delivery.  She receives the wrong baby. 

3)      A nurse arm carries a baby into a treatment room and leaves the empty bassinet in the hallway.  A second empty bassinet is left in the same hallway while the baby is being weighed.  The first nurse brings her baby back to the bassinet, but does not check the crib card and places her baby in the wrong bassinet.  Another mother/baby mix-up has just occurred. 

4)      Two babies in infant warmers are placed side by side.  At some point-in-time, the babies kicked their I.D. bands off their feet.  A nurse working in the area notices that neither baby is wearing an ankle I.D. band.  She immediately looks on the floor at the foot of each infant warmer and sees two I.D. bands.  She picks the bands up and places them back on each baby’s ankle.  They are inadvertently placed on the wrong baby.  Unfortunately, the wrong mother and baby were discharged from the hospital.

5)      Two babies having the same last name, or the exact same names are inadvertently transferred to the wrong mother.  Only their name was checked and not their I.D. number. 

 

Prevention:

 

The mother/baby unit policy should state that anyone authorized to transport infants, must verify the baby’s I.D. number with the mothers’.  The infant’s I.D. number is read out-loud to the mother and the mother reads her number back to the nurse out-loud.  Each time a baby is transferred to or from an infant carrier or crib, the crib card I.D. number should be read out-loud as well as reading the baby’s I.D. number to verify that the crib-card number matches the infant I.D. number.  The baby’s Infant identification band is to be put on the infant’s ankle at birth, before the mother and baby leave the delivery room. 

 

 

Baby Matching Systems

 

Ninety-Nine percent of the time Mother/Baby Mix-Ups happen because of human error.  This occurs when a nurse or staff member accidentally gives the wrong baby to the wrong mother. The weakest link in the security chain is, and has always been, human error.  Depending solely on human accuracy is a practice fraught with problems.  As a result, several electronic infant protection system manufactures have developed electronic Mother/Baby Mix-Up protection.  An infant protection and mother matching tag are attached to baby’s ankle at birth.  Each time the baby is taken to the mother’s room mother/baby matching takes place electronically.  Once the match is authenticated electronically, the baby is given to the mother.  Hospitals that purchase new or replace existing infant electronic protection systems need to make sure that the replacement system selected has electronic matching capability.  When selecting an infant protection system it is essential that the system alarms when:

 

  • the tag or bracelet is cut or tampered with,
  • anyone, without password authorization, attempts to exit  the mother/baby unit through a protected doorway.
  • an infant is brought within the protection area of a doorway
  • a password authorized exit has occurred and a second person tries to “piggyback” through the protected exit with an infant not authorized to leave the unit
  • an alarm occurs at an exit, the system should display the specific floor plan showing that exit and the baby’s tag on the screen
  • the system can interface to other devices such as CCTV cameras, door locks, pagers, and elevators
  • infant at an exit, door should automatically lock

 

Any system you select should be designed for self-testing and supervision.  Tag status should be available at any time, and loss of signal or “low battery” should immediately generate a response.  The bracelet material should contain no latex and be non-allergenic, as well as water-proof to allow infants to be bathed.  The system selected should have the capability to interface with CCTV cameras, door locks, pagers, and elevators.  When an infant comes in close proximity to an exit door the door should lock automatically and the system should alarm.

 

One of the most important features of an infant electron protection system is the support provided by the manufacturer / vendor.  Any system should also have the capability to expand to provide protection for future growth of the maternal / child care facility.

 

CASE STUDY #1021 - HOSPITAL MOTHER / BABY MIX-UP

 

The victim hospital in Southern California had been consistently below their staffing requirements for some time and very seldom followed their policy and procedures during the discharge of their mothers and babies.  As a result of lax procedures, the wrong baby was given to a mother being discharge and she ended up taking the wrong baby home with her.  Immediately, an investigation was completed by the Department of Facility Services and the hospital was cited for not following hospital procedures.  The facility was also cited for chronic understaffing on the maternity unit, and four nurses were charged with failing to properly match the mother to her baby.  Two of the nurses responsible for the mother/baby mix-up were fired and two others were suspended.  Under staffing was listed as the number one contributing factor to the mother/baby mix-up and the state’s report charged that the hospital was in violation of nurse-patient staffing rations as outlined by the American College of Obstetricians and Gynecologist (ACOG) and the American Academy of Pediatrics (AAP).  Documentation showed that on one shift one RN was responsible for providing care for 16 patients.  The hospital stated the citation the hospital received for failing to report the incident in a timely manner was caused by a holiday and a three day week-end.

 

Contributing Factors / Vulnerabilities  Unique to this Case

 

·          Failing to follow policy & procedure

·          Quality Control not established for discharge

·          Unacceptable nurse-patient ratio

·          Failure to report in a timely manner

·          Frequent under staffing 

·          Limited Parental Education

·          Inadequate Physical Security

·          Policy not enforced by management

 

Preventive Measures

 

1.     Provide on-going, in-service education for all staff on all policies and procedures  

2.     Develop a policy that requires a second nurse to verify matching at discharge 

3.     Require the infant’s I.D. number to be read out loud by the nurse to the mother

4.     Require the mother to read the infant’s I.D. number to be read back to the mother

5.     Evaluate nurse-patient staffing ratios on a regular basis.

6.     Educate parents on their responsibility to assist in the proper identification of their baby

7.     Verify babies in the unit with the same last name

8.     Babies with identical names should have a special tag that reads “Please verify my Name”.

9.     Never carry more than one baby at a time into a semi-private room.

10.   Consider upgrading or replacing your infant electronic protection system with a mother/baby mix-up protection and alarm.

 

 

NOTE: Consult with a Healthcare Security Professional with expertise in infant and pediatric security to assist you and your staff in developing the most effective and cost efficient security program for your facility.  In most cases, a security professional can save the hospital considerably more money than would be spent on the consultant’s fee.  SAI has written an educational pamphlet – Infant Security – How Parents Can Help designed to assist hospitals in educating new mothers and their families, and meet Joint Commission requirements.

 

 

Mother/Baby Mix-Ups - IN THE NEWS

 

Mother/Baby Mix-Ups

http://www.saione.com/mixups.htm

 

Baby Mix-Up At Norton Hospital  - Louisville, KY

http://www.saione.com/Baby_Mixup_at_Norton_Hospital.pdf

 

Hospital baby mix-up renews old fears  - By Stephen Smith, Boston Globe Staff

http://www.saione.com/hospital_baby_mix_up_renews_old_fears.pdf

 

Preview:  "Baby Swap" - a NewsPronet Interactive Special Report produced by SweepsFeed

http://www.saione.com/13930-BabySwap.wmv

 

 

On-line resources

 

The Case for Mother / Infant Matching

http://www.xmarksystems.com/pdfs/hugs_news_q2_2004.pdf

 

Media Interview Q & A with Jeff Aldridge, CPP

http://www.saione.com/mediainterview.htm

 

Litigation Avoidance

“There is a significant chance that the hospital will be sued when an infant abduction or mother/baby mix-up occurs.

 

 

Future Newsletter Topics

 

 

Fallacy of Foot Printing – Is Foot printing a "thing of the past?”

Hospital Liability - “An Abduction or Mix-Ups Can Cost a Hospital Millions”

When to hire a Security Expert”

Components of a “Self-Assessment”

How to conduct a successful “Code Pink”

Educating Employees and Staff

“Pros & Cons of an Infant Protection System”

Mother/Baby Mix-Ups  - “How to Prevent the Unthinkable”

 

 

 

Disclaimer

 

Advice given in this "Newsletter" is general in nature, and subscribers (readers of this material) should consult with professional counsel for specific legal, ethical, or clinical advice.  The information provided in the SAI Newsletters is for educational purposes only and should not be considered 'legal' advice.  Websites listed are for reference only and are provided for subscribers (readers of the material) to have an opportunity to read the original documents in total.  Please consult your legal counsel or Compliance Officer for clarification of laws and rules related to your State when applicable.

 

 

 

SAI is not affiliated with the Joint Commission on Accreditation of Healthcare Organizations.

 

 

SAI - ©January, 2005