Newborns in Sydney hospitals are regularly becoming victims of distressing mix-ups including being allocated to the wrong mother, fed the wrong breast milk, mistakenly given x-rays or even given the wrong blood type in transfusions.
Just a few weeks after two babies at one Victorian hospital were handed to the wrong mothers, a Nine News investigation has revealed 25 adverse event reports into bungles in Sydney public hospital maternity wards, including seven alone in 2010.
In one case at St George Hospital that occurred on December 5, 2010, a radiographer failed to check a baby’s wrist ID band before subjecting the wrong baby to chest x-rays from a mobile machine after nursery staff indicated the wrong crib. The treatment was intended for a baby in an adjacent crib.
An inquiry into the matter gave the incident an Actual Severity Assessment Code rating of "serious" requiring a root cause analysis report.
At the same hospital, on October 15, 2010, radiographers commenced an abdominal ultrasound on a baby less than four weeks old for 15 minutes before staff realised it was the wrong baby. This matter was regarded less serious in possible consequences than the December 5 bungle.
Adverse incident reports, accessed from local health networks under Government Information (Public Access) 2009 laws for the period January 1, 2008 to December 31, 2010, detail all adverse incidents in maternity wards involving breast milk and medication mix-ups and wrong identification.
Seventeen of the mistakes reported were due to feeding babies breast milk from the wrong mother.
The reports show nursing or admin staff are to blame for many of the expressed breast milk mix-ups, despite strict protocols that require two nurses to sight and sign off the allocation before feeding can begin.
At Nepean Hospital last year, a report shows a baby was given reheated frozen expressed breast milk left behind in the fridge by a patient earlier discharged with the same surname. Sixty-five millilitres were taken by the baby before the mother noticed the wrong initials on the bottle.
The report into the incident notes the expressed breast milk stored in the freezer of the infant that was discharged "should have been disposed of".
It added: "Container … should have had warning label advising that there were two infants with the same surname in the unit."
As is often the case with breast milk mistakes, the baby was "aspirated" to suck out the milk and 40mls was removed from the child's stomach and blood tests conducted of mothers and the babies to check for communicable diseases including HIV, Hepatitis B and Hepatitis C.
In another breast milk mix-up last year at Nepean, a 63-day-old baby being treated in an incubator was fed another mother's breast milk via naso-gastric tube. The milk for two different babies in adjacent incubators were simply swapped. The milk was immediately aspirated.
At least two other cases involved babies given to wrong mothers like the Geelong cases, but thankfully all were sorted without harm.
At Royal Hospital for Women on February 26, 2008, a baby girl in the nursery was handed to a mother for breastfeeding during the night by nursing staff. The father was asleep on the floor and the lights were dim.
An undisclosed time later, after a 15 minute feed, the baby started to cry and the father came over the comfort the baby.
The report states: "Father opened nappy to see what baby had done and discovered that instead of a boy baby he found the baby to be a girl."
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