Breastmilk Errors

klone, MSN, RN · Apr 5, 2015

Yes, I have.

The mother of the child was notified that her child received someone else's milk. HIV and HBSag was retested on the other mother while she was there to make sure she didn't have any new infections, and the first mother was reassured that her baby would be fine.

That's about it.

tinkerbell419 · Apr 5, 2015

Oh god, may I ask what caused you to make that mistake? My confusion was caught by another nurse because the baby in question required medications to be added to the milk. I instantly threw the milk away. What didnt help really was that i had another baby on ebm milk with meds to be added, who had 2 names in use. Parents had obviously changed her name at some point and so names were starting to merge together.

I know i should check hospital numbers not just check the name only. Anyway i can confirm that neither babies had any wrong milk because i threw everything away. Anyway the parents must have found out and have gone mad having blood tests done on the baby. I feel awful.

I have never made a near miss before and ive been in my job for quite a few months now.

So did you not face any sort of punishment or disciplinary action for that mistake? Did anyone senior question you or ask you to write a statement of facts.

Exactly how harmful could giving another child the wrong milk be out of curiosity? I realise that i need to view breast-milk in a different way as a body fluid rather than a bottle of milk. :/

klone, MSN, RN · Apr 5, 2015

I was charge nurse that night, and the nursery nurse asked me to take the baby out to the mother, along with the syringe of expressed colostrum so she could feed her baby. She pulled the syringe out of the fridge and put it in the bassinet with the baby. I brought the baby out to the mother's room. When I got there, the baby was starting to cry from hunger, but the mom really had to get up and go to the bathroom. She asked me to go ahead and feed the baby the colostrum. I did so, without first verifying the patient label on the syringe.

When I went to toss the syringe, I saw The name did not match the baby and mom's name. It was another baby's colostrum.

I immediately filled out an incident report, notified my manager, and the baby's pediatrician. I did not name the other nurse at any time, because ultimately it was totally my fault for not doing the correct rights before administering the colostrum.

No, I did not get written up or in trouble. My manager asked me what I learned, and I told her simply that I must do all rights every time, and not rely on another nurse's judgment.

The amount of colostrum given to the baby was less than half a milliliter. Even if the mother had been HIV-positive, that amount would likely have not caused any issues whatsoever. I was far more upset by the error than anybody else.

NicuGal, MSN, RN · Apr 5, 2015

We now have to scan all our milk. I was the charge nurse when we had a few errors before scanning started. As above all parents were notified, the nurses were counseled and written up for one of them as the mom was a methadone mom and Hep C positive..

klone, MSN, RN · Apr 5, 2015

Yes, we did not have electronic MARs or barcode scanning at that time.

tinkerbell419 · Apr 6, 2015

But what are the risks for example if a child does accidentally have someone else's milk?

AnnieOaklyRN, BSN, RN, EMT-P · Apr 6, 2015

I am not a NICU nurse, but I am wondering if anyone knows how long HIV survives in breast milk, especially if it has been refrigerated?

Annie

klone, MSN, RN · Apr 6, 2015

But what are the risks for example if a child does accidentally have someone else's milk?

Other than transfer of infections such as HIV and hepatitis, and any drugs the mother may have had, there are no other risks.

klone, MSN, RN · Apr 6, 2015

I am not a NICU nurse, but I am wondering if anyone knows how long HIV survives in breast milk, especially if it has been refrigerated?
Annie

That's a good question that I do not know the answer to - I will try to get that information for you today, if someone else doesn't post.

tinkerbell419 · Apr 6, 2015

Hi Klone did you manage to find out any further information?

NICURN29 · Apr 6, 2015

There is very minimal risk to a baby getting the breast milk of another mother.

Here is some information from the CDC...Breastfeeding: Recommendations: Another Woman's Breastmilk | DNPAO | CDC

This is basically the information we give to a mother whose baby got fed another mother's milk, and we follow these recommendations.

I have not made a breast milk error, but we have had some in our unit. The people who have made the errors were placed on corrective action but not removed from their position. We put some process changes in place to help provide opportunities to double check our milk at the bedside with another nurse before feeding. And when we transition to Epic next year, we will start scanning our milk.