The role of critical incident monitoring in detection and prevention of human breast milk confusions.
- Resource Type
- journal article
- Authors
- Zeilhofer, Ulrike B.; Frey, Bernhard; Zandee, Jeanette; Bernet, Vera
- Source
- European Journal of Pediatrics. Oct2009, Vol. 168 Issue 10, p1277-1279. 3p. 2 Graphs.
- Subject
- *BREAST milk
*NEWBORN infants
*MOTHERS
*INFANT care
*MILK
*INTERMEDIATE care
*PREVENTION of medical errors
*CHI-squared test
*NEONATAL intensive care
*QUALITY assurance
*TASK performance
*NEONATAL intensive care units
- Language
- ISSN
- 0340-6199
Feeding a mother's expressed breast milk to the wrong infant is a well-known misidentification error in neonatal intermediate care units (NICU) with potential harmful consequences for the neonate. In this study, we aimed to analyze the role of critical incident monitoring on detection and prevention of human breast milk confusions. The critical incident monitoring made us aware of this misidentification error on our NICU. Despite the implementation of system changes to make breast milk application clearer and safer, we failed to reduce the incidence of breast milk confusions. [ABSTRACT FROM AUTHOR]