New mothers and maternity centers alike live in fear that babies will be discharged to the wrong family. The Joint Commission considers discharge of an infant to the wrong person a never event, and it’s no surprise. Even if the mix-up is quickly rectified, huge problems can ensue.
Luckily, we don’t have to wait until an incident happens to us. We can instead perform a proactive root cause analysis, where we consider what COULD go wrong to result in an infant being discharged to the wrong person. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.
For our very basic Cause Map, we can consider that two things have to happen in order for a infant to go home with the wrong family. First, the wrong baby has to be given to a family, and second, the matching system has to be ineffective. We’ll break each of these causes down into more detail.
The matching system may be ineffective because it isn’t being used. If a facility doesn’t have a matching system, it obviously won’t be effective. Additionally, if a computerized system is in use there is always the possibility that it won’t be working. Or the staff may not know how to use the system, possibly due to lack of training or insufficient staffing.
If the system is being used but not being checked, it won’t be effective. Again, this could be because the staff doesn’t know how to use the system, or it could just be that the discharge personnel forget.
The wrong baby could be given to a family if the matching system is on the wrong infant. (This is only likely to happen if the matching system is put on outside the delivery room.) Or, the wrong baby could be in a bassinet. This could happen if the baby is kept in an nursery and a nurse is transporting more than one baby..
It’s possible to add even more detail to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals. Once the Cause Map is complete, solutions can be brainstormed that match up with causes. The solutions are shown on the downloadable PDF.
Click on “Download PDF” above to download a PDF showing the Cause Map and Solutions.