Baby Mix-Up at KKH

4 FEB 2013

QUESTION NO. 884

Name of Person: Mrs Lina Chiam

QUESTION

To ask the Minister for Health (a) how the recent baby mix-ups at KK Women's and Children's Hospital whereby two sets of parents were given the wrong newborns to take home came about; (b) how many of such mix-ups have occurred in Singapore in the past ten years; and (c) what measures, procedures and other safeguards will be put in place to ensure that such mix-ups do not occur again

ANSWER

1        The recent baby mix-ups at KKH is an unfortunate incident that has caused much distress to the parents involved.  In the last ten years, there has not been any reported incident of the same nature. The Ministry of Health takes a very serious view of this. As soon as the incident was notified to MOH, I directed MOH and KKH staff to find out how the mix-up could have happened and work with the hospital to prevent similar lapses in future.

2        As soon as a baby is born in KKH, an identification tag bearing the mother’s details is affixed to the baby’s right ankle in the delivery suite. The mother’s details are also affixed onto a cot that will be used throughout the baby’s hospital stay. Thereafter, when the baby has arrived in the ward nursery, a second barcode tag is affixed to the baby’s left ankle. This barcode tag is unique to the baby and used to confirm the identity of the baby electronically before medications are served or investigative procedures are carried out.

3        The KKH case involved two babies, Baby A and B. Baby A was born on 16 November 2012, while Baby B was born on 17 November 2012. Both babies were correctly tagged and placed in the correct cots soon after birth. For most of the admission, the babies were roomed with their mothers, but in the early morning of 18 November 2012 between 3.15 am and 11.30 am, both babies were in the ward nursery and cared for by the nurses. We believe that it was during this period that the two babies were inadvertently placed in each other's cots. The mix up occurred when they were removed from their cots for care at about the same time and were returned to the cot without counter-checking their tags to ensure they were returned to the correct cot. KKH was unable to ascertain the precise moment of the mix up as unlike activities such as administration of medication where the exact time was recorded, the time of activities such as bathing, changing and soothing a crying baby were not recorded.

4        A second error occurred when the barcode tag on Baby A’s left ankle dropped off and was wrongly replaced with Baby B’s tag. The staff replacing the missing tag failed to counter check the identity of the baby against the remaining right ankle tag and most likely relied on the identity on the cot itself, which showed details of Mother B and Baby B.

5        Subsequently, the baby thought to be Baby B was brought to Mother B and the baby thought to be Baby A was pushed to Mother A. The staff who brought the wrong babies to the mothers had failed to check both ankle tags against the cot card. Both discharge staff had also failed to open the baby’s blanket to check both ankle tags when the mothers were discharged with their babies.  When KKH was alerted to the error, it made immediate arrangements to reunite the babies with their rightful parents. Unfortunately, unwarranted distress had already occurred.

6        Since then, a specially-commissioned review committee has completed its investigations on the incident.

7        The review committee found that although protocols for the handling of babies were in place, there were lapses in compliance with established policies and procedures. There were indications of lax supervision and inadequate audits and checks imposed by hospital management.  In other words, the unfortunate incident could have been avoided if those involved in caring for the affected babies had followed the proper procedures.

8        The review committee has recommended improvements to patient care and ward processes, staff education, protocol compliance and supervision, governance, as well as IT enablers.  KKH has already implemented most of these recommendations and is also evaluating possible IT solutions that could further strengthen the current manual processes. Details of the actions taken have been announced by KKH on 26 Dec 2012. For example, two staff are required to tag or re-tag babies to ensure they are correctly tagged. Patient identification procedures will be reinforced during staff orientation and training. Regular and ad-hoc audits will be carried out to ensure compliance.

9        KKH has taken disciplinary actions against the respective staff responsible for the lapses, as well as the ward managers. The staff have also personally apologised to the affected parents.

10      MOH has also written to the CEO of KKH to register its deep disappointment and concern over the lack of oversight and supervision, especially with regard to patient safety in the nursery. KKH’s Patient Safety Committee will step up its oversight of patient safety and ensure supervision and compliance of protocols by staff. KKH will also undertake a comprehensive review of its quality assurance framework to further enhance patient safety.

11      We will learn from this incident. It should be a reminder to all healthcare institutions in Singapore, both public and private, to strengthen their quality assurance programmes to improve patient safety and outcomes. MOH will continue to work with all healthcare institutions to ensure appropriate actions and measures are taken and sustained to achieve the highest level of patient safety possible.