Chasing Zero: Reducing Breast Milk Feeding Errors in a Tertiary NICU

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Advisor: James Pelegano, MD, MS

Second reader: Tracey Hoke, MD, MS


Breast milk is the optimal nutrition for most infants who are cared for in the high-risk location of a neonatal intensive care unit. As many of these infants cannot be fed by mouth and must be fed by a gavage feeding tube due to prematurity or other medical conditions, their mothers must express breast milk, which allows for the possibility that the wrong breast milk could be given to an infant. The NICU at the University of Virginia recently had an incident of breast milk being given to the wrong infant. A multidisciplinary project team was developed and a root cause analysis was performed. The project team recommended several changes to the process of breast milk feeding and several measures were monitored for compliance with the changes. Although nearly 100% of nurses verified that they were aware of the changes, compliance to the new process was variable. Part of the lack of compliance may be related to issues with the electronic medical record, but other issues must also be considered. After implementation of the recommended changes to the breast milk feeding process, a failure modes and effects analysis was also performed. The project team is continuing to monitor compliance rates as well as evaluate the possibility of further changes to the process of breast milk feeding to ensure that the University of Virginia NICU has no further incidents related to errors of breast milk feeding.

Presentation: 27 minutes

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