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
"ABIES IN BED
3ECURE !REA 7AITING 2OOM
"ABY ON CHANGING STATION
Figure 5. Neonatal care unit system showing RFID tags and readers, mobile devices, kiosk, and wireless network.