According to Reena Oza-Frank, PhD, a registered dietitian, principal investigator at the Center for Perinatal Research at Nationwide and the study’s lead author, breast milk errors can have disastrous results.
“It is a bodily fluid,” she says, meaning it could transmit infectious diseases. For instance, application of milk to the wrong baby typically leads to infectious disease testing for the donor mom, the recipient baby and the recipient mom.
“Our motto here is breast milk is medicine,” she says, so breast milk errors could also be seen as a medication error.
A study out of Nationwide Children’s Hospital in Columbus, Ohio, recently published in Pediatrics, shows how the hospital reworked its process for administering breast milk in the NICU and the results of that change.
Nationwide’s NICU is one of the largest of the nation, totaling 114 neonatal beds. According to the study, 60 percent of the hospital’s infants are on human milk at any given time, opening the hospital up to the possibility of error.
In 2008, the hospital started a quality improvement journey to lower the rate of breast milk errors in its NICUs. Before the interventions, Nationwide saw:
- 84.0 expired milk errors per 1,000 bottles
- 4.8 preparation errors per 1,000 bottles
- 8.3 wrong milk to wrong baby errors per 1,000 bottles
Errors were identified through a human milk bar code medication administration system.
The quality improvement initiative involved several facets, but according to Dr. Oza-Frank, these three had the biggest impact.
1. Installing bedside barcode scanners. When the scanning system was first implemented, the scanners were only available at centralized areas in the NICU. When bedside scanners were installed it led to lower error rates, Dr. Oza-Frank says.
2. Hiring dedicated milk technicians. Previously, the nurses or patient care assistants would handle storing, labeling, fortifying and dispensing the milk. But they have many other patient care responsibilities, Dr. Oza-Frank says. When Nationwide brought on dedicated milk technicians — whose sole responsibility is handling all aspects of breast milk — it helped bring about a “significant drop in error rates,” she says.
3. Using magnets as labels. While the first two interventions were the most effective, they can also be cost prohibitive. A smaller intervention that worked in the study was using magnets on the outside of breast milk refrigerators to identify location of patient feeding bins.
After implementing these three interventions, the breast milk error rates fell substantially. Specifically, error rates were as follows after the quality improvement initiative:
- 8.9 expired milk errors per 1,000 bottles
- 2.2 preparation errors per 1,000 bottles
- 2.0 wrong milk to wrong baby errors per 1,000 bottles
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