Baby Suffers Brain Damage After Delay in Newborn Testing Results

By ThinkReliability Staff

A recent watchdog report by the Milwaukee Journal Sentinel found that 3.9% of screenings from a particular hospital took 5 days or longer to reach the lab, though the state guidelines are 24 hours.  (Statewide, 2.9% of samples take five days or more.)   This typically occurs because of a practice called “batching”, where multiple samples are saved to send in as a group.  Although the practice of batching is not recommended, and the state guidelines warn “DO NOT BATCH SPECIMENS”, there are no laws requiring hospitals to send in samples within the 24 hours, nor are there are penalties for not doing so.  According to the state’s newborn screening advising committee, some hospitals continue to batch samples, even though it is the state – not the individual hospitals – that pay to have the blood samples sent to the lab.

A case turned tragic illustrates the problem with waiting to send these blood samples.  We can capture the cause-and-effect relationships that led to a baby suffering brain damage within a Cause Map, or visual root cause analysis, which allows a detailed examination of the issues that led to the nearly fatal outcome.

On October 2, 2012, a baby was born at a Wisconsin hospital.  Per guidelines, a blood sample was taken for newborn screening when the baby was 32 hours old.  However, that blood sample (likely due to batching, though the hospital has not officially confirmed this), was not sent to the state lab until October 8.  The state lab tested the sample October 9 and determined that the baby had Argininosuccinic aciduria, which occurs in only 1 of 70,000 babies in the US. Though it can be fatal, if it’s caught early, the treatment involves some extra care with feeding and an extra day or two in the hospital.

In this case, because the sample was delayed, a diagnosis wasn’t made before the baby had lapsed into a coma.  He was transferred first to a larger hospital, then to one of two hospitals in the state that can perform newborn dialysis – necessary due to his off-the-charts ammonia levels.  A quick-thinking doctor utilized a novel technique of cooling that baby, which saved his life.  The cost of all this treatment was nearly $500,000 and the baby has suffered brain damage, though the extent is not known.

The Journal Sentinel has published data showing how long samples took at Wisconsin hospitals in an attempt to raise public consciousness of this issue.  The state, as well as other experts, continues to advise hospitals of the importance of sending blood samples to the lab for screening within the recommended 24 hours.  It could save a life.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.