Why the final baby-to-bottle scan is insufficient?

When the Institute of Medicine published its groundbreaking report To Err is Human in 2000, patient safety moved to the forefront of healthcare initiatives throughout the US. From instituting electronic medical records in hospitals nation-wide to transitioning to barcode-scanning systems for medication administration, the face of healthcare in 2017 is very different than it was in 2000.

Except when it comes to breast milk.

While the rest of healthcare evolved, the management and preparation of breast milk in neonatal intensive care units (NICUs) remained largely unchanged. To date, there exist no universally accepted, national guidelines or standards that regulate the management and preparation of breast milk in hospitals. In the Philadelphia region alone, individual hospitals and NICUs have different rules for storage and preparation of human milk. Traveling between NICUs in Philadelphia will find breast milk managed with barcoding systems and/or manual preparation, labels ranging from pre-printed to handwritten, and refrigeration storage guidelines that range from 48 hours to 96 hours.

So why does it matter? Why care about breast milk?

Of the 4.5 millions babies born each year in the US, 1 million of them will spend time in neonatal intensive care; and this number is on the rise. For infants in neonatal intensive care, breast milk is medicine. An incontrovertible body of evidence proves that NICU infants who receive their mother’s breast milk have better outcomes and leave the hospital sooner. In response to the Healthy People 2020 goal to improve breastfeeding rates throughout the country, hospitals and many respected organizations like the American Academy of Pediatrics strongly advise exclusive breast milk for the first 6 months of life. For sick and at-risk NICU babies, breast milk is recommended as the front line choice for any feeding.

Consequently, overall breastfeeding rates are on the rise. More breast milk is now available in NICUs than ever before.

While the benefits of breast milk for these vulnerable infants are well known, breast milk itself is a body fluid. Despite the fact that overall risk remains low, diseases like HIV, HTLV, Hepatitis B, and CMV are all transmitted through breast milk. If a baby receives the wrong breast milk, follow-up may necessitate lab work for the baby and both mothers.

The mistake may be reportable to the Joint Commission. For both the families and healthcare workers involved, there is stress, disappointment, shame and loss of confidence.

What complicates things further is that feeding an infant another woman’s milk is not the only type of breast milk error.

Breast milk management in NICUs is exceedingly complex. A majority of infants in neonatal intensive care require additional additives to meet nutritional demands. Most infants are on restricted volumes of breast milk – sometimes as low as 1mL per feed – requiring healthcare providers to “bartend” each shift. When bottles of pumped milk are split into smaller volumes and then mixed with additional additives, expiration times changes and room for error increases.

Feeding an infant expired breast milk may increase their risk of infection while feeding an infant milk with the wrong additives may increase their risk of feeding intolerance.

NICU nurses generally have 2-4 infants in their care eating 6-8 times/day. At max, a nurse could potentially prepare 24 feeds in one day. Without a barcoding system, this preparation time requires a heavy toll of mental validations on the part of the nurse. A FMEA at a large urban hospital in Philadelphia found as many as 15-20 mental validations are required to prepare feeds for one infant. Another study of manual breast milk preparation found that in one week on an average-sized NICU, there are 32 critical failure modes in breast milk preparation and administration that require human detection to prevent.

Still, manual breast milk preparation without the aid of barcoding technology remains prevalent throughout the country.

Some EMR’s have added a single barcode scan at the point of administration to match breast milk with the correct infant, but that does nothing to address the heavy risk for error found in the receiving, preparation and storage of breast milk prior to feeds. A recent large scale Six Sigma Study put the overall risk for breast milk error to be 1 in 10,000 feeds – that’s the monthly feeding total for most average-sized NICUs.

For the nurses and healthcare providers working in neonatal intensive care, the safety and health of babies is paramount. These special clinicians dedicate their lives to the care of our country’s smallest humans. We owe it to them and the babies in their care to provide the safest, most efficient technology to keep infants growing strong and healthy without risk of error.

Drenckpohl, D., Bowers, L, & Cooper, H. (2007). Use of the six sigma methodology to reduce incidence of breast milk administration errors in the NICU. Neonatal Network, 26(3): 161-166.

Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (2000). To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press.

Fleischman, E.K. (2013). Innovative application of bar coding technology to breast milk administration. Journal of Perinatology and Neonatology Nursing, 27(2): 145-150.

Schelbred, A. & Nord, R. (2007). Nurses’ experiences of drug administration errors. Journal of Advanced Nursing, 60(3), 317-320.

Steele, C. & Bixby, C. (2014). Centralized breastmilk handling and bar code scanning improve safety and reduce breastmilk administration errors. Breastfeeding Medicine, 9(9).

Wolford, S.R., Smith, C., & Harrison, M.L. (2013). A retrospective two year study of breast milk error prevention in the neonatal intensive care unit. Neonatal Intensive Care, 26(2); 41-42.

Zhang, B., LaFleur, E., Ballweg, D.D., Mulholland, K.L., Wild, J.A., Shedenhelm, H.J., Stirn, S.L., Fjerstad, K.A., & Morgenthaler, T.I. (2014). Use of healthcare failure mode anaylsis (HFMEA) to quantify risks of human milk feeding process. Journal of Nursing Care Quality, 29(1): 30-37.