“Get a really good look at her,” I kept saying to my husband when we arrived at Sibley Memorial Hospital, a well-regarded Washington D.C. hospital. “Take a selfie with her as soon as she’s out.” My rational husband rolled his eyes, especially when we took a tour of the birthing suite and saw that if the baby was healthy, she was not going to leave the room.
Finally, our daughter was born, fat and happy. Reassured, we let her be taken to the nursery, and the next morning, though we expected to have her back at 6 a.m. to breastfeed, she returned at 8 a.m. The lovely nurse said, “Your baby will get her jaundice test again today, and she was given to the wrong mother this morning.” It was said in the tone of, “Here is some Starbucks. You’re welcome.”
She explained that another nurse had brought our daughter from the nursery to the wrong room but that she quickly realized her mistake and retrieved her before the other mother touched her. Not wanting to be those over-reactive new parents, we said, “Oookayyy,” and let it go.
But that evening I started to panic. “What if the other mother has Ebola? How does the nurse know what happened in the other room when she wasn’t there? What if the mother fed her?”
“Do you want to speak to someone more senior?” was my husband’s reply, to which I gave a tearful yes.
Another nurse came late that night — but only because we requested her to — and her story was very different. The other mother, who had a son, had held our daughter and fed her formula before the panicked nurse came in and took her away. The hospital then contacted their lawyers, the nurse explained, which is all well and good, but why had they barely contacted me? And changed their story?
In the maternity ward of Sibley, each new mother is given a bracelet with a 10-digit number on it, and when the baby is brought back to her, the mother and nurse confirm that the number matches the baby’s bands. I was told that my bracelet and the other mother’s bracelet were only one number off from each other and that the mother who had my daughter confirmed the number, even though it was wrong, hence the mix-up. So according to the hospital it was mostly her fault.
I asked the second nurse about the feeding and she assured me that my baby only drank formula, not breast milk, which seemed like a stroke of luck as that could have elevated my terror to a code red, but the fact that my baby had formula was another kind of disappointment. I was committed to only breastfeeding and had lactation consultants working with me around the clock to get the colostrum going. So despite my wishes and efforts, my baby had gulped down formula.
Distraught at this point, I was unable to enjoy anything about being a new mom, so my husband decided to launch his own investigation. “I’ll just find this woman and we can talk to her,” he said.
By walking the hospital halls, and glimpsing a piece of paper with two room numbers written on it, one of them ours, he was able to find the mother and ask her to speak to me. She very kindly came to my room and explained that no, it was not her who read the bracelet number wrong, it was the nurse, and she had in fact held my baby and given her formula. Newborn babies, we agreed, can look very similar, especially in the same outfit, and when you have only seen them for a few hours. She offered to show us her medical records and expressed her panic over where her baby was when she had mine. We then compared hospital bracelets and our numbers were quite different, not one number off as the first nurse had stated.
I was calmer after I spoke to this kind, Ebola-free mother, but why did my husband have to find her on a covert ops? I understand that there are privacy laws under HIPAA and the hospital could not have simply wheeled her in and said talk amongst yourselves, but there must have been something they could have done to appease me rather than repeat, “Our lawyers are taking this very seriously.” Because to me that just meant, “We’re making sure we’re covered in case you’re a litigious snake,” instead of, “We are doing everything we can so you don’t leave this hospital traumatized.”
All my panic and tears aside, my biggest question looking back is about the kind of security measures used in the maternity ward. Why are sleep deprived new mothers expected to confirm a 10-digit number every time they see their child? There must be an easier way.
For starters, it seems like a no-brainer to ask a mother to verify her last name and her child’s gender. And how about using some sort of bracelet scanning device, like they use for dispensing medicine, instead of relying on the exhausted mother’s ability to recite numbers. I’m surprised they didn’t throw in some long division to really challenge us.
At the end of our hospital stay, my husband asked that the switched-at-birth debacle be entered into our daughter’s medical records and that we receive a copy of the incident report. Three months later, neither has happened. Instead, we received one phone call after we returned home, where we again stated the above. They promised to follow up and never did.
My experience at Sibley led me to question what other hospitals do for security in the maternity ward and Sibley’s procedure seems to be pretty standard. A spokeswoman for George Washington University Hospital commented that there, “All infants receive two identification bands at the time of delivery that are placed on their wrist and ankle. The mother and a designated support person will wear matching bands. The mother will need to wear these bands until she and her baby are discharged. Each infant also has a ‘safe place’ security band applied in Labor and Delivery that will set off an alarm if the infant is taken out of our locked Women’s Center area.” Sibley does not use alarmed bands, but it would not have made a difference in my case if they did.
When I reached out to Northside Hospital in Atlanta, which delivers more babies than any other community hospital in the nation, a spokesman emphasized their rigorous security protocols but chose not to go into details, expressing concern that making them public might make them easier to crack.
I followed up with Sibley for comment on this article and, not surprisingly, they were very apologetic and helpful. They offered for us to come in to speak to a neonatologist and an infection control specialist, which I do appreciate, but I should have been offered that opportunity when the incident occurred, along with a straight story. Now, the hospital is sending us my daughter’s updated records, but they said they will not release the incident report. They also issued a kind apology to me, and I’m thankful for it, I just wish I hadn’t had to say the words, “I’m writing an article about…” to get it.
Gary Stephenson, director of public relations at the hospital wrote, in part, “We want to apologize personally to you and explain that we took the error in the feeding process of your baby very, very seriously and we understand that your questions about the process to be followed were not resolved with clear explanation of how mothers and babies are identified regularly for the feeding sessions and how this process needs to be improved to rely on not just the mother but also the staff member delivering the baby. We have taken action to learn from this error and added one more step to assure we avoid another incident like the one you unfortunately had experienced.”
The hospital also offered to show me their patient safety initiatives first-hand, including their Innovation Hub, which is “Fully staffed with human factors engineers and clinicians” and “ focuses on the design thinking process to solve a clinical problem.” And their Comprehensive Unit-based Safety Program (CUSP), which “provides all staff, the tools and support needed to address problems such as hospital-acquired infections, medication errors, and communication breakdowns.”
Let’s hope that these safety measures, along with Sibley’s added level of security in their maternity ward, keeps the old baby switcheroo from ever happening again, for while I was at the hospital, one nurse said an incident like ours had not occurred since 1983 and another said the same thing happened three years ago. Conclusion: It happens. But seems so preventable. Because I’m pretty sure we have the right baby, but when she screams bloody murder at 2 a.m., I do still wonder.
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