Patient Safety Topics
Breast Milk

Education and communication are crucial to providing safe feedings of expressed breast milk (EBM). Staff knowledge of EBM management is essential to maintain a reliable system. Mothers require education at the time of admission, with emphasis on the importance of following labeling and storage directions for EBM. Additionally, mothers need basic instruction in how to safely express or pump their milk, as well as guidelines for storage, including transporting EBM.

Considering the thousands of feedings delivered and the multiple steps in handling EBM, relatively few occurrences in which a baby received the wrong EBM have been reported through PA-PSRS as of a 2007 published analysis. However, when an event occurs, staff and parents experience anxiety. Implementing a standardized approach to the management of EBM mistakes can provide comfort and reassurance. Nurses can be knowledgeable of the risks to the infant, as well as testing to be performed.

Key Data and Statistics

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.
Educational Tools

​Plan of Care for Infant(s) When Breast Milk Mismanagement Occurs
This stand-alone, plan-of-care algorithm can guide staff when mismanagement of expressed breast milk occurs.

Sample Policy for Mismanagement of Expressed Breast Milk
There is no "one size fits all" policy statement related to mismanagement of breast milk. Policies that suggest a standardized treatment require medical review appropriate for the population involved and condition being treated.

Risk of Infection from Breast Milk Mismanagement—Parent Information
This sample handout for parents about the risk of infection related to breast milk mismanagement can be adapted to be facility-specific.

Risk of Infection from Breast Milk Mismanagement—Staff Information
This sample handout for staff about the risk of infection related to breast milk mismanagement can be adapted to be facility-specific.


​Visit this section in the future for any multimedia associated with this patient safety topic.



Safety Tips for Patients