New guideline will improve newborn safety at hospitals
There have been cases where the wrong baby was taken to the operating room for surgery, or sent home with another baby's mother
The Joint Commission, an organization that accredits hospitals, announced a new standard requiring extra security for newborn patients called a “National Patient Safety Goal.” The new standard goes into effect on January 1, 2019, and requires all hospitals to use distinct methods of identifying newborn patients.
As bizarre as it sounds at first, the idea behind the new policy requirement is that it is easy to get the wrong baby. The more you think about it, though, the more you can appreciate the risk. Newborns cannot speak, do not have names immediately at birth, and, at first, many of them look roughly alike. Plus, in many hospitals newborns are separated from their mothers and put in a nursery for sleeping or treatments.
As a Houston, Texas medical malpractice lawyer, I have seen several issues come up with newborn misidentification. In addition to the nightmare scenario of having parents take the wrong baby home from the hospital, there are additional risks.
Mixing up a baby can result in feeding one mother’s breastmilk to someone else’s newborn. Even worse, think about a baby born with a brain injury or a condition requiring surgery. Without strong identification standards in place, the wrong baby could be taken to the operating room for an unnecessary procedure.
For that last risk, you may think that could never happen. Yet, I am currently working on a medical malpractice lawsuit now where a patient (an elderly woman, not a newborn) was mistaken for someone else and taken to the operating room for a painful, unnecessary surgical procedure.
The new safety requirement
The Joint Commission’s National Patient Safety Goal 01.01.01 EP 3 requires hospitals to use distinct methods for the identification of newborn patients. Acceptable examples that hospitals could implement include:
· A naming system incorporating the mother’s first and last names and the newborn’s sex. An example would be “Doe, Jane Boy” or, in the case of twins, “Doe, Jane Girl A” and “Doe, Jane Girl B.”
· A standard policy for using identification banding. For example, using identification bands on the wrist and ankle, and barcodes.
· A policy requiring staff to be proactive by communicating particular risks with each other, which could be done, for example, by posting signs noting newborns with similar names. By the way, this would have helped in the misidentification case that I am handling right now—two female patients had the same last name, and the surgeon and nurse got the wrong one.
Before I became an attorney, I was a hospital administrator. One of my responsibilities was to make sure our hospital complied with Joint Commission standards. I can assure you that hospital leadership takes Joint Commission requirements seriously, and this new standard will improve the safety of newborn patients and the peace of mind of their parents.
This reminds me of a funny situation when my wife and I had our first child, at St. Luke’s Episcopal Hospital (now Baylor St. Luke’s Medical Center), in Houston, Texas. We had a smooth labor and delivery, and then my wife was moved to a room on a different floor and the nursery was just down the hall.
The second morning after delivery, she was scheduled to be discharged from the hospital. A nurse brought our daughter to us and signed off on all the paperwork. We waited awhile and then decided to leave. Someone caught us before the elevators and explained that we had to be escorted off the floor and out of the hospital, to prevent a newborn mix-up. Looking back, it seems that, in 2005, that hospital was already meeting the 2019 Joint Commission standard.
We are here to help
If you, your newborn baby, or a loved one has been seriously injured by a hospital, physician, or nursing error, our experienced medical negligence attorneys can help. Click here to send us a confidential email via our “Contact Us” form or call us at 281-580-8800.
All consultations are free and, because we only represent clients on a contingency fee, you will owe us nothing unless we win your case. We handle cases in the Houston area and all over Texas. We are currently working on medical malpractice lawsuits in Houston, The Woodlands, Sugar Land, Conroe, Dallas, Austin, San Antonio, Corpus Christi, Bryan/College Station, and Waco.
Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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Published in the July/August 2018 edition of "The Houston Lawyer" magazine