After a newborn baby at a Minneapolis hospital was placed in the wrong bassinette, he was delivered to the wrong mother and breastfed. Because breastfeeding can carry risks of transmission of communicable diseases the CDC recommends HIV and hepatitis testing after such events.
We can examine this incident – and what went wrong – in a visual root cause analysis, or Cause Map. The Cause Mapping procedure begins by determining the impact to the organization’s goals. In this case, the patient safety goal is impacted due to the risk of transmissible disease. The hospital involved has stated there will be consequences to staff for not following hospital procedure. This is an impact to the hospital’s employee impact goal. The patient services goal is impacted because babies were switched (and apparently misplaced for some period of time) and because of the testing that the baby who was breastfed by the wrong mother will require. The hospital will pay for the testing, which can be considered an organizational goal impact.
The analysis step of the Cause Mapping process begins with the impacted goals. To continue the analysis, we ask “why” questions. The patient safety goal is impacted because of the risk of disease. The risk of disease is caused by being breastfed by the wrong mother. This occurred because the wrong baby was brought to the mother, the mother was breastfeeding, and the infant’s bands were not matched to the mother’s bands, although this was hospital procedure. According to the hospital’s statement, “While hospital procedures require staff to match codes on the infant’s and mother’s identification bands in order to prevent incidents like this, it appears these procedures were not followed in this case.”
The wrong baby was brought to the mother because multiple babies were kept in bassinettes in the nursery, and the baby had been placed in the wrong bassinette. It is unclear what procedure was used to determine which bassinette the baby should be placed in, but the procedure was obviously ineffective.
The hospital has stated that its procedures will be reviewed. Certainly the procedure to verify a baby’s wristband to a mother’s will be emphasized and retrained. Additionally, matching of the baby’s wristband with a tag on the bassinette would reduce these types of issues. Some hospitals have gone so far as to stop using nurseries where multiple babies are placed and instead keep the newborn in the mother’s room. This also would reduce the risk of baby switching incidents.
To view the Outline, Cause Map and potential solutions, please click “Download PDF” above.