A Quality Improvement Project to Decrease Human Milk Errors in the NICU.

Area of Science:

• Neonatal Intensive Care Unit (NICU) safety
• Quality Improvement in Healthcare
• Medication Administration Safety

Background:

• Human milk administration in NICUs is complex and prone to errors.
• Wrong milk to wrong infant administration is a critical safety concern.
• A quality improvement initiative was implemented to address these errors.

Purpose of the Study:

• To describe a quality improvement initiative.
• To report the reduction in human milk administration errors over six years.
• To identify interventions contributing to error reduction.

Main Methods:

• Quasi-experimental time series design.
• Utilized Model for Improvement and Six Sigma methodologies.
• Monitored scanned errors (wrong milk, expired, preparation) using barcode medication administration system and statistical process control charts from 2009-2015.

Main Results:

• Total scanned errors decreased from 97.1 to 10.8 per 1000 bottles (2009-2015).
• Expired milk errors reduced from 84.0 to 8.9 per 1000 bottles.
• Wrong-milk-to-wrong-infant errors decreased from 8.3 to 2.0 per 1000 bottles.

Conclusions:

• The quality improvement initiative successfully reduced human milk administration errors.
• Bedside scanners and dedicated milk preparation staff were key interventions.
• Reduced errors enhance patient safety in the NICU setting.