By Lena H. Sun
Washington Post Staff Writer
Wednesday, July 28, 2010; A01
The day after her first child was born in January at Virginia Hospital Center in Arlington County, Suzanne Libby discovered that he was missing from the hospital nursery. Searching frantically, she found Spencer in his hospital bassinet -- in another woman's room. Standing next to him was a hospital aide, a stricken look on her face.
The relief that Libby felt at finding her son was later replaced by fresh anxiety: The woman, it turned out, had breast-fed her newborn.
More than two hours passed before hospital officials told Libby, 34, and her husband, Reed, 36, how the mix-up had happened: The aide had neglected to match Spencer's ID bands with the other woman's. The next day, hospital officials told the couple that results of blood tests run on the woman showed she did not have HIV or hepatitis B or C, diseases that can be passed to a baby through breast milk.
It's impossible to know how often breast-feeding mix-ups happen, because many states do not require hospitals to report them unless there is serious harm.
But Ruth Lawrence, a breast-feeding expert at the American Academy of Pediatrics, says that she hears about them occasionally.
At least eight other mix-ups have occurred in recent years, including two at other Washington area hospitals where babies were given to the wrong mothers but not breast-fed.
Although some experts say the potential for harm to infants is minimal, federal authorities say the possible exposure to HIV or other infectious diseases should be treated just like an accidental exposure to other body fluids.
The incidents also point to a larger problem of accurate patient identification -- a major cause of health-care errors. That is a particular risk with newborns, and experts say sleep-deprived mothers are sometimes confused: It can be hard to recognize a swaddled infant brought by the nursing staff for feeding in the middle of the night.
For the past few months, the Libbys say, they have asked hospital officials to put in writing the verbal assurances they were given. They want a list of tests and results, including a toxicology screening, that were performed on the woman who breast-fed their baby. The hospital has not provided them.
Last month, the hospital's risk-management officer, Susan Richardson, sent a lawyer hired by the Libbys a two-sentence letter that expressed regret and said: "Please know that after looking into the matter the Virginia Hospital Center has no knowledge of anything indicating that the woman who breast-fed Spencer Libby on Jan. 31, 2010, exposed him to any disease, toxin or other harmful substance."
In response to a reporter's inquiry, Virginia Hospital Center said in a statement July 14 that one employee was fired after she "failed to follow standard protocol." The hospital also said that it had "conducted comprehensive laboratory tests and has no knowledge of anything indicating that the woman who mistakenly breast-fed the infant exposed the infant to any harm" and that it had "taken the necessary steps to ensure that this situation does not happen again."
Hospital officials declined to elaborate, citing patient confidentiality.
The Libbys are looking into legal options.
"It was the worst moment of my entire life," Libby said, when she realized her son was missing and nurses didn't know where he was. "On top of that, to find that another mother breast-fed him, without my knowledge, without my consent, was horrid. . . . He was exposed to someone else's body fluid."
Her concern is that the mistake not be repeated, she said.Identity checks
Hospitals use information on a newborn's and mother's ID bands to try to prevent such errors. Security has increased since two baby girls in Virginia were discovered 15 years ago to have been switched at birth. Many hospitals, including several in the Washington area, say mothers are asked to say their name and their baby's name as an additional check before nurses hand over a baby.
In profitable services such as labor and delivery, hospitals often boast about security in their marketing materials. That was one reason the Libbys said they chose Virginia Hospital Center, a 334-bed community hospital that had 3,800 births last year.
The hospital's Web site promised vigilant monitoring, saying that only nurses, doctors, the mother or someone she designates are allowed to take a baby out of the mother's room, the nursery or the neonatal intensive care unit. The employee who moved Spencer from the nursery was a patient-care assistant, the Libbys said.
After being contacted by The Washington Post, a hospital spokeswoman said the Web site information was incorrect, and it was changed to say that properly trained patient-care assistants can move infants.
States typically don't require hospitals to report breast-feeding mix-ups unless a patient is harmed. But the Virginia Department of Health is investigating the Virginia Hospital Center incident after receiving a complaint, said Chris Durrer, who oversees hospital licensure and certification. The Libbys said they filed the complaint.'You just got lucky'
At Sibley Memorial Hospital in Northwest Washington, what hospital officials described as a "near miss" with a breast-feeding mother occurred last year, but the woman and a nurse realized the mistake before the infant ingested breast milk. In addition to verifying ID bands, hospital employees transport only one crib at a time, a Sibley spokeswoman said.
In April 2005, a newborn was put in the wrong bassinet by Georgetown University Hospital staff and was taken to the wrong woman, but the baby refused to feed, said the mother, who did not want to be identified. A hospital spokeswoman said that she couldn't comment on specific cases but that employees are "continually trained and retrained" on patient identification.
Officials at Washington Hospital Center, George Washington University Hospital, Shady Grove Adventist Hospital and Washington Adventist Hospital said they were not aware of such incidents.
Two systems that handle a high volume of births would not say whether they've had breast-feeding mix-ups: the Inova hospitals in Northern Virginia, which had 21,000 births last year, and Holy Cross Hospital in Silver Spring, which reported 9,000 births, the most in Maryland.
At least six other errors have occurred at hospitals in Illinois, Massachusetts, New Hampshire and New York. There were no reports of physical harm to the newborns. At least three cases involved nurse's aides, according to media reports and documents.
After a mix-up in 2003 at South Shore Hospital in Weymouth, Mass., the facility added a chime to ID bands so they ring when a baby is brought to the correct mother, a spokeswoman said.
Lawrence, the breast-feeding expert, played down the possible harm to infants, citing the use of wet nurses in many cultures.
But others disagree. "HIV can be found in breast milk, as well as many drugs," said Paul Hain, associate chief of staff at Monroe Carell Jr. Children's Hospital in Nashville.
The larger issue concerns errors in identifying patients, he said. In an initial audit, Hain found that 20 percent of his hospital's patients had wristband ID errors, including illegible and inaccurate data. Such errors could result in the wrong treatment.
In the Libbys' case, he said, "you just got lucky."A moment of panic
Suzanne Libby gave birth to a healthy 7-pound, 3-ounce boy at 8:40 p.m. on Saturday, Jan. 30. Everyone remarked on his full head of dark hair. Not yet named because he arrived a week early, his hospital wristbands called him "Libby Bb," for "Libby baby boy." Nurses put a blue knit cap on his head soon after he was born.
Libby knew she wanted to nurse as soon as possible. She breast-fed him two hours after the birth and several more times, recording the feedings on a clipboard hanging from his bassinet. The baby stayed in her room.
By 4 the next afternoon, Libby was exhausted. She and her husband decided that Spencer, who had been named that morning, could go to the nursery so she could rest. Reed couldn't find their assigned nurse. But the patient-care aide who had been assisting them offered to help. Reed asked her to take Spencer to the nursery, and then he went home.
About two hours later, Libby went to the nursery to check on Spencer. Right away, she noticed something was wrong. Of the three babies there, only one had lots of dark hair. But he didn't look like Spencer. A white hat was in the bassinet, not a blue one.
She asked whether someone had changed Spencer's hat. "No" was the reply.
Libby panicked. "There's no baby in there with a blue hat," she remembered telling the nurses. As staff scrambled, someone yelled for the aide.
Heart racing, Libby headed down the hall. All of a sudden, she saw Spencer, in his bassinet, wearing his blue hat, in another woman's room. She overheard the aide saying "Libby, Libby" in a confused manner, and an older woman say, "But he looks just like our baby."
Libby became hysterical.
"I'm thinking, 'Oh, my God, that's my baby in there.' I start screaming, 'She has my baby, she has my baby.' And I'm shaking and I'm crying."
She returned to her room, and someone brought Spencer back. She called her husband, who rushed back to the hospital.
At 6:30 p.m., Libby tried to feed Spencer, but he wouldn't eat. That's when she noticed the feeding log had an entry of 5:43 p.m., in someone else's handwriting. At 8 p.m., the hospital's associate director of patient relations confirmed what Libby suspected: "Your baby was breast-fed by another woman," Libby recalled her saying.
Libby, a lawyer who works for a government agency, said she started taking notes to keep track of what was happening.
She still struggles to put into words how the incident has affected her.
After watching a recent episode of the TV series "The Office" in which Jim mistakenly hands the wrong baby to his wife, Pam, for nursing, Libby said the difference was that it wasn't "my goofy sitcom husband" who made the mistake: "It was the hospital staff who took my baby out of the nursery and gave it to someone else."
She continued: "I know it wasn't my fault, but I feel like the first 24 hours of my baby's life, I failed to protect him," she said. "There was a period of time where I don't know whose care he was in. . . . And every time I think about his birth, this is what I think about."
Research editor Alice Crites contributed to this report.