mix-up of babies
Hospital in baby mix-up
Short on Nurses
Tests Show Virginia
Babies Were Switched
Parents Sent Home
Swapped Babies, Shattered Families
Hospital Baby Mix-Up Renews Old Fears
Nurse fired after babies 'swapped'
Mother wary of
to sue hospital
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
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
Routing: [ ] Facility Services [ ] Security
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“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
The following information is designed to assist individual hospitals
in preventing mother/baby mix-ups through staff awareness, education and best practices.
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.
“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.
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
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.
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”
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).
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.
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.
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.
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.
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.
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.
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
Provide on-going, in-service education for all staff on all policies and procedures
Develop a policy that requires a second nurse to verify matching at discharge
Require the infant’s I.D. number to be read out loud by the nurse to the mother
Require the mother to read the infant’s I.D. number to be read back to the mother
Evaluate nurse-patient staffing ratios on a regular basis.
Educate parents on their responsibility to assist in the proper identification of their baby
Verify babies in the unit with the same last name
Babies with identical names should have a special tag that reads “Please verify my Name”.
Never carry more than one baby at a time into a semi-private room.
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
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
Baby Mix-Up At Norton Hospital - Louisville, KY
Hospital baby mix-up renews old fears - By Stephen Smith, Boston Globe Staff
Preview: "Baby Swap" - a NewsPronet Interactive Special Report produced by SweepsFeed
The Case for Mother / Infant Matching
Media Interview Q & A with Jeff
“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
Educating Employees and Staff
“Pros & Cons of an Infant Protection System”
Mother/Baby Mix-Ups - “How to Prevent the Unthinkable”
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