• Article
  • October 12, 2017

How One Children's Hospital Virtually Eliminated Breast Milk Administration Errors

A team identified 282 potential failure points in the process.

3 tips for children's hospitals

CHOC's breast milk administration program is one of the first to incorporate bar code scanning into a centralized process, and was recognized as a 2015 Pediatric Quality Award Semifinalist and by HIMSS.

Here are three tips for hospitals looking to implement a program:

  • Learn from experience. CHOC has hosted a number of hospitals from around the world to learn from their experience in building this program.
  • Make it your own. Create a program that fits your hospital and culture.
  • Seek grants. This can help pay for upfront technology costs and gain buy-in from administrators.

When Christine Bixby set out on a career path in medicine to help others, she didn't expect to make her impact with process improvements, or to help her institution virtually eliminate breast milk administration errors.

"I'm a doctor, and I'm making a difference," says Bixby, M.D., medical director of lactation services and a neonatology specialist at Children's Hospital of Orange County (CHOC). "But I'm doing it in a way I never thought I would. When you realize what you're doing affects so many babies and children by changing a process it has impacted more babies than I could in a regular clinical day or even a clinical month."

For Bixby, the impetus for change came about six years ago. Over a two-year span, CHOC experienced three breast milk administration errors, as well as 16 near-misses—incidents where breast milk was incorrectly labeled but did not reach the patient.

Bixby and her team spent most of 2012 analyzing the entire breast milk administration process and identified 282 potential failure points. Primary among them: inadequate double checks at key points in the breast milk administration process that could lead to misadministration. To address this issue, CHOC decided to centralize its breast milk administration process.

Centralizing the process

In January 2013, CHOC moved the management of breast milk administration from the individual patients' nurses to a nutrition lab staffed by two registered dietetic technicians (DTRs.) The DTRs were responsible for preparing breast milk for all patients, ensuring label accuracy and freshness of the milk. The presence of two DTRs also allowed for a double check to further promote flawless execution. 

But this process was manual and subject to a degree of human error. The centralization of breast milk administration did yield positive results: CHOC had no breast milk administration errors in 2013. But there were still four labeling errors, as well as three storage errors. All of those potential errors were caught before the milk was administered, but the potential for misadministration due to human error underscored the need for further process improvement.

Adding technology

In November 2013, the hospital implemented bar code scanning into the breast milk administration process. Each baby has a tag with a unique bar code matching the breast milk labels. DTRs scan the labels and tags prior to feeding to ensure accuracy.

Additionally, DTRs scan pumped milk into inventory in the nutrition lab to track the volume, location and expiration dates of all milk for an individual patient. The scanning prior to milk preparation and feeding eliminates the need for two DTRs to perform a double-check. Finally, the scanning system automated the process of calculating breast milk volumes and additives based on the order in the electronic medical record, as well as the printing of labels.

As a result, breast milk administration errors at CHOC have been virtually eliminated. In the nearly four years since the implementation of the bar code scanning process, there have been just two errors. The team continues to examine the process for improvement opportunities, and a yearly refresher on the process is part of annual competency training for the nursing staff.

Cost savings and safety

The implementation of the system has had a financial impact on the hospital. It has eliminated the need to staff two DTRs at all times, as well as cut the time nurses spend on breast milk administration—freeing them up for other patient care duties. CHOC estimates an annual savings of $30,000 in salary, benefits and related costs, but Bixby says the real bottom line is safety.

"I know these babies are getting the safest food," Bixby says. "The most important thing we do in the NICU help babies grow so they can mature and do all the work of being alive on their own and succeed."

Send questions or comments to magazine@childrenshospitals.org.