A 2007 published analysis addressed the more than 30 cases involving breast milk reported through PA-PSRS. Of these, approximately 20 reports indicated that an infant had been fed another mother’s expressed breast milk (EBM). Other problems identified include labeling issues, identification or verification issues, and storage issues (i.e., refrigeration or freezing systems malfunctioned).
The following cases are indicative of these problems:
Nurse removed wrong breast milk from refrigerator to be given to baby. Mother started to feed and noticed a different label on bottle. Mother brought mistake to nurse’s attention. Baby took 5 cc before error realized. Certified registered nurse practitioner was informed of error. HIV testing done on mother whose milk the baby took, and all tests negative.
During finger feeding, it was discovered that a baby was receiving breast milk intended for another baby. The infant was fed approximately 15 cc of breast milk.
After a baby received two feedings of breast milk from a bottle labeled with the baby’s name, the baby’s mother reported that she had not expressed any milk. Investigation revealed that the bottle had been mislabeled.
A refrigerator used to store breast milk was found not working; the milk was warm, although the temperature on the refrigerator had been checked daily and recorded within the appropriate range. All EBM was discarded, and a new refrigerator was obtained.Excerpted from: Mismanagement of expressed breast milk. PA PSRS Patient Saf Advis 2007 Jun. http://patientsafety.pa.gov/ADVISORIES/Pages/200706_46.aspx.