Newborn Breast-Fed by Wrong Mother

http://www.washingtonpost.com/wp-dyn/content/article/2010/07/27/AR2010072705976.html?wprss=rss_print

The day after her first child was born in January at Virginia Hospital Center in Arlington County, Suzanne Libby discovered that he was missing from the hospital nursery. Searching frantically, she found Spencer in his hospital bassinet — in another woman’s room. Standing next to him was a hospital aide, a stricken look on her face.

The relief that Libby felt at finding her son was later replaced by fresh anxiety: The woman, it turned out, had breast-fed her newborn.
More than two hours passed before hospital officials told Libby, 34, and her husband, Reed, 36, how the mix-up had happened: The aide had neglected to match Spencer’s ID bands with the other woman’s. The next day, hospital officials told the couple that results of blood tests run on the woman showed she did not have HIV or hepatitis B or C, diseases that can be passed to a baby through breast milk.

It’s impossible to know how often breast-feeding mix-ups happen, because many states do not require hospitals to report them unless there is serious harm.

Ruth Lawrence, a breast-feeding expert at the American Academy of Pediatrics, says that she hears about them occasionally.

Although some experts say the potential for harm to infants is minimal, federal authorities say the possible exposure to HIV or other infectious diseases should be treated just like an accidental exposure to other body fluids.

The incidents also point to a larger problem of accurate patient identification — a major cause of health-care errors. That is a particular risk with newborns, and experts say sleep-deprived mothers are sometimes confused: It can be hard to recognize a swaddled infant brought by the nursing staff for feeding in the middle of the night.

Last month, the hospital’s risk-management officer, Susan Richardson, sent a lawyer hired by the Libbys a two-sentence letter that expressed regret and said: “Please know that after looking into the matter the Virginia Hospital Center has no knowledge of anything indicating that the woman who breast-fed Spencer Libby on Jan. 31, 2010, exposed him to any disease, toxin or other harmful substance.”

In response to a reporter’s inquiry, Virginia Hospital Center said in a statement July 14 that one employee was fired after she “failed to follow standard protocol.” The hospital also said that it had “conducted comprehensive laboratory tests and has no knowledge of anything indicating that the woman who mistakenly breast-fed the infant exposed the infant to any harm” and that it had “taken the necessary steps to ensure that this situation does not happen again.”

Hospital officials declined to elaborate, citing patient confidentiality.