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CHOC describes how it eliminated human errors

Friday April 4, 2014
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Jenn Landman, RN
The first phase of CHOC’s new expressed breast milk process began in January 2013, with nurses collecting the expressed breast milk labeled by mother’s name and putting it in a freezer for the nutrition lab to pick up. The lab then processed sufficient milk for the next shift, fortifying it if needed and properly labeling it, before putting it in
the refrigerator.

Error rates in wrong milk to going patients at CHOC decreased during the first phase by 300%. The hospital had three incidents between May and December 2013 and has had none since. The hospital also experienced a 75% reduction in labeling errors and an 88% decrease in storage errors of putting the milk in the wrong baby’s bin.

During the second step in November 2013, the hospital added barcodes to the milk. From implementation through Jan. 19, 2014, the system has picked up 27 near misses of wrong milk to the wrong baby and 58 near misses of expired breast milk. There have been no incidents of wrong milk reaching the wrong baby nor has expired milk been fed since launching bar coding.

“Having the barcoding takes the human error out of the equation,” said CHOC NICU nurse Jenn Landman, RNC. “It gives you the confidence you are giving the right milk to the baby, that it has not expired and has the right fortification.”

To see the full story about CHOC's breast milk initiative, visit http://news.nurse.com/article/20140404/CA01/140402011#.Uz7TCqMo40A.


Debra Anscombe Wood, RN, is a freelance writer. Post a comment below or email editorWest@nurse.com.