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Addressing Mother-Baby Mix-ups

Well-documented cases in the healthcare industry describe the unfortunate scenario in which a baby is given to the wrong mother, either at the hospital, or at discharge.

The mix-up can last a few minutes, a few hours, and sometimes longer. Even mixing baby and mother for a single breast-feeding session is traumatic and complex, and creates the possibility of litigation.

The following facts apply to mother-baby mix-ups in the U.S. alone, and demonstrate the need for a mother-baby ID system:

• It is estimated that there are approximately 4.2 million live births in the U.S. each year; 3.9 million in hospitals with a c u t e c a r e f a c i l i t i e s 1 .

  • The average length of stay (ALOS) for mother and baby is 24 hours for normal births or 72 hours for complicated deliveries and caesarean sections.

  • A healthy baby and mother spend 24 hours in the hospital; complicated deliveries or caesarean sections require a longer stay, typically 72 hours.

  • During initial hospital stays, infants are transferred to and from mother approximately 23 million times each year.

  • There are approximately 23,000 erroneous infant-mother transfers per year.

  • 64 mother-baby mix-ups occur per day—a rate of 2.7 mix-ups per hour.

  • The vast majority are discovered before discharge, usually through pure luck.

Hospitals have identified the following causes of mother-baby mix-up; most falling in the human error category:

  • Misreading infant or mother bracelet information

  • Bracelet falling off ankle or wrist, which is particularly common with newborns, whose arms and legs may shrink after birth due to water loss

  • Bed mix-ups, in which a child is removed for bathing

or treatment then returned to the wrong bed

  • Mix-ups of babies with similar or identical names

  • Misreading of sequential names or ID numbers

  • Inadequate physical security mechanisms

  • Parents who are not fluent in the staff’s native language

  • -

    AIN

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"ABIES IN BED

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"ABY ON CHANGING STATION

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Figure 5. Neonatal care unit system showing RFID tags and readers, mobile devices, kiosk, and wireless network.

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