Recommendations to prevent future baby mix-ups: Review committee

SINGAPORE - The committee came up with 15 recommendations, which have been thoroughly reviewed by the Health Ministry.

The measures that have been implemented include:

• Proper documentation for tracking the movement of babies in and out of the nursery.
• Proper documentation for replacement of dislodged tags in clinical notes.
• Babies being fed in close proximity to their respective cots.
• A registered nurse and a staff member being involved in the tagging and re-tagging of babies at all times to ensure the information on the tags is correct.
• Further review and enforcement of hospital guidelines on patient identification. Proper patient identification carried out before and/or after each diaper change, bathing, feeding, screening or assessment, and handover of babies.
• Involving both the nursery and the ward staff in the discharge process of the baby to the mother.
• Reviewing the design of cot cards so that essential identifiers are prominently and clearly displayed. This is to be implemented next month.
• Tagging both ankles of babies at birth (pilot programme to be implemented next month).

Measures under evaluation include:

• Patient identification to be confirmed before the discharge process can be completed as an additional safeguard.
• On top of the committee's recommendations, KKH has independently implemented additional measures, said Ms Tan Soh Chin, director of its nursing department. These include:
• Tighter procedures for newborn identification.
• Daily audits by senior staff, and regular and frequent cross-departmental audits, to reinforce familiarity and to ensure compliance with protocol.
• Greater engagement of parents in verifying the babies' identity and accuracy of information on the tag at birth, at the ward nursery and during discharge.
• Recording and reporting incidents of tagging errors.
• Use of education materials to orientate, train and remind nurses of the revised protocol for newborn identification, and reiterate the implications of non-adherence.

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