Intermountain and hospitals across the country have seen infant breast milk being given to the wrong baby. Exposure to another mother’s breast milk should be treated as seriously as exposure to any other bloodborne pathogen. As a system, we can avoid mix-ups by using the error prevention techniques STAR and Standardized Hand Offs.
Here’s how we improve using STAR:
STOP - Ask yourself, “Do I know the policies and guidelines around breast milk handling and administration?”
THINK - Ask yourself, “Am I aware of the dangers of administering breast milk to the wrong baby?”
ACT - Complete all patient identification verification steps including documentation in real time.
Review – Ask yourself, “Was there anything unique about this situation I should share with my peers or those caring for the infant?”
Use a Standardized Handoff following these steps:
- Patient identification
- Plan of care
- Purpose
- Problem(s)
- Precaution(s)
Read about a recent safety event involving a breast milk mix-up in this week’s “Lessons Learned.”