Electronic tagging to prevent mother and baby mix-ups -- MEDICA - World Forum for Medicine


Scan Modul Stanley Healthcare Solutions

Electronic tagging to prevent mother and baby mix-ups

Electronic baby tagging systems are being adopted worldwide to help mitigate the risk of abduction of newborn infants from the maternity ward. Such events, while rare, have devastating consequences for all concerned: infant, mother, family and staff.

There is, however, another risk facing newborns that is much more common, yet just as serious – mother and baby mix-ups. There are no official statistics on either infant abductions or incorrect transfers, but in the US it is clear that the latter is much more common. Infant abductions are tracked by the National Centre for Missing and Exploited Children, which records, from 4,000,000 live births, between five and 10 abductions from hospitals a year. This compares to an estimated 26,000 incorrect transfers of an infant to its mother.

Extrapolating from these figures, it suggests one or two abductions a year from hospitals in England and Wales from 700,000 births annually, compared to perhaps as many as 4,000 mistaken transfers. Most mismatches are quickly corrected before there is any serious impact, but a few lead to a mother nursing the wrong infant and, very occasionally, to discharge of an infant to the wrong family – an outcome every bit as serious as an abduction.

The standard defence against this risk is the matching band system, where the infant and mother wear bracelets with pre-printed identical numbers. Typically, additional information such as the mother's name is also written in by the midwife or an assistant.

The matching bands system is effective and low-cost, but it is also entirely manual, relying on the midwife to correctly read the information. It is thus prone to human error, and, in fact, mismatches have been traced to all of the following perfectly understandable human failings:
• Misreading infant or mother bracelet information;
• Misreading of sequential names or ID numbers;
• Mix-ups of babies with similar or identical names;
• Cot mix-ups: a baby is removed from a cot, then returned to the wrong cot;
• Bracelet falling off the ankle or wrist.

Many hospitals have chosen to address these shortcomings by adding mother/infant matching to their electronic baby tagging system. By providing early notification to caregivers of a potential mismatch, electronic mother and baby matching is an excellent back-up to the matching bands system.

In a typical application, each mother wears a small wrist tag that is bonded with her child's baby tag. If the wrong infant is brought to the mother, the caregiver is immediately alerted. Depending on the technology, this can be a totally automatic process that requires no additional steps for the caregiver. The event can also be recorded in the software. In some jurisdictions, mother and infant matching is as important a priority as preventing abductions.

The Ministry of Health of Saudi Arabia, for example, has recently selected electronic baby tagging systems for 17 of the largest birthing hospitals in the kingdom, including four with over 10,000 births a year.

It's an indication that hospitals across the globe are increasingly focused upon the risks associated with mother and baby mix-ups, and understand the value of electronic matching as an added layer of protection.