A Nurse Manager’s Perspective on Breastmilk Safety

NICU baby at Fort Worth hospital fed breast milk from mom with damaging virus – Fox4News Report ℹ️

We all know that the NICU is an intense and complex clinical environment where you are dealing with the most precious of patients. Specifically, the topic of infant feeding management involves some of the most challenging and complicated clinical, educational, operational and administrative decisions.

I have had the honor of being a NICU nurse for 15 years and the last six years of my career, I had been a Nurse Manager.

“What gets watched gets done” is an old adage we all think about when we start to plan new initiatives or while handling ongoing practices. However, what we often forget is that what doesn’t get watched still gets done, it still happens. And I do not mean best practices, I mean errors.

If you consider the recent milk misadministration events in Texas, you will realize how prevalent feeding errors are.

The Dreaded Reality

I distinctly remember a “near-miss” event where a nurse came into my office and told me about a possible error in feeding milk to the wrong baby. Beyond immediately supporting my staff member(s), my task list grew by a hundred to-dos, all while keeping a game face on. From investigating the incident, to simultaneously notifying relevant members of the care team, while coordinating with the infection prevention team, risk management team, patient and guest relations and worst of all, communicating with the families involved.

Thankfully, in this case, there was no error made, but it just as easily could have been.

The Complexity of Milk Management

Infant feeding management is extremely complicated, if not one of the most complicated processes at a hospital/NICU. Period. The steps include – Receive, Combine, Fortify (with an ever-increasing list of bovine fortifiers, additives, donor milk and human milk fortifiers), Split, Feed, Discharge + expiration updates, property updates, and so on and so forth.

As the science behind infant-specific fortification gains further momentum, a baby’s growth is tied to even more complex recipes and needs more attention to ensuing details.

Feeding management at different hospitals can be best laid out on a 2×2 grid, based on automation and safety of systems and processes in place.

The Manual Process Delusion

On one end of the spectrum, we have institutions who claim to have “no errors with 2-RN/Tech checks”! Having experienced the complexity of feeding management first-hand, and the management of feeding management – I absolutely refuse to believe that. As leaders, we need to pull our heads out of the sand and truly acknowledge that manual 2-RN/Tech check processes are wrought with errors and despite everyone’s best intentions people make mistakes – mistakes that do not get caught/recognized.

Average milk preparation and feeding process involves 32 critical failure modes that require human detection to prevent errors.

It is humanly impossible for manual checks to catch that many errors while preparing 10,000 feeds/month.

The Medication Scan Insufficiency

Many institutions employ EMRs that treat breastmilk as a medication in an effort to check the safety box and move on. While we can all, philosophically and clinically, agree this to be true, it is extremely lacking when considered in terms of safety management. These systems simply provide the final confirmation of a baby-to-bottle match during feeding, which although a critical step, misses the multitude of other preparatory steps – each as important as the one before it.

Read here why the final baby-to-bottle scan is insufficient. ℹ️

The Legacy System Fallacy

A small percentage of hospitals in the US are using one of the few legacy options available in the market. These antiquated feeding management system at least provide some level of automation to this massively manual process. These systems, while “market-leading” in early 2000s, have failed to keep up with the times and requirements of today’s feeding management.

The recent hospital errors in Texas clearly highlight the gaps in old-school barcoding systems – can we do better?

A study at Penn Medicine calculated that, on one such legacy system, 13,000 nursing hours were spent per year for an average sized NICU, to prepare and feed milk. That is equivalent to 6.5 full-time nursing employees, who had to spend all their time away from critical care to use the product.

Workarounds are inherently created when staff does not have the right tools or processes to do their jobs. And when workarounds happen, errors can happen – defeating the entire purpose of installing a technology.

The Modern Barcoding Magic

Up until now, we did not truly have an option to ensure the safety of every single step of the feeding management process, starting with the mom and ending at the baby.

However, that changes with modern technologies like Keriton Kare that allow for a truly automated and efficient feeding management experience and much more. The Keriton platform meets a hospital’s requirement from every aspect – safety, efficiency, transparency, complex workflow management, reporting, and auditing!

Keriton was designed with nurses, nurse managers, lactation consultants, dietitians and moms and the co-innovation with the end-users shows in how well the final product works. Some key Keriton results thus far have been –

  •  $2.5M prevented in HIPAA fines through robust validations at every step of the process, without 2-RN/Tech checks.
  •  2x faster than other legacy barcoding systems with extremely efficient workflows that start with the mom. Be it bedside preparation or milk room setup, be it on smartphones or desktops – Keriton works for all configurations.
  •  $60K worth of labels saved, per year, by not constantly re-labeling bottles after every step.
  •  40% increase in mom’s milk receieved at the hospital due to real-time lactation intervention and patient engagement.
  •  93% nurses would recommend Keriton, compared to 3% recommendation for legacy system.

The Time Is Now

As leaders, we are responsible for giving our staff the tools they need to do their job and do it well. While the rest of healthcare evolved, the management and preparation of breastmilk/feedings in NICUs remained largely unchanged. To date, there does not exist any universally accepted, national guidelines that regulate feeding management in hospitals. Let’s change that now. Equip your staff with state-of-the-art technology and ensure 0 feeding errors at your hospital with the new gold standard in infant feeding management.

Interested in learning more – we are happy to setup a call. Contact Us!