How a QI Intervention Lowered Breast Milk Errors in a Busy NICU

How a QI Intervention Lowered Breast Milk Errors in a Busy NICU 150 150 Kevin Mayhood

Bedside barcode scanners and dedicated milk preparation technicians helped drive the decline.

A quality improvement (QI) initiative in the Neonatal Intensive Care Unit (NICU) at Nationwide Children’s Hospital has been associated with a substantial reduction in errors administering mother’s milk to these vulnerable infants.

The total number of scanned errors declined from 97.1 per 1,000 bottles in 2009 to 10.8 in 2015, driven primarily by installation of bedside bar-coding scanners and dedicated milk technicians who prepare, store and dispense human milk in a centralized milk room.

Scanned errors are, as the name implies, detected by the barcode scanning system, which warns the user before actual errors are made.

“By reducing the number of scanned errors, we also reduce the opportunity for actual errors,” says Reena Oza-Frank, PhD, RD, an epidemiologist and principal investigator in the Center for Perinatal Research at The Research Institute at Nationwide Children’s. “That’s an important step toward improving patient safety.”

Dr. Oza-Frank is lead author of a study reporting on the QI initiative, published in the February issue of Pediatrics.

During the six years studied, wrong-milk-to-wrong-infant scanned errors dropped from 8.3 per 1,000 bottles to 2 per 1,000. Expired milk error scans declined from 84 per 1,000 bottles to 8.9 per 1,000 and preparation errors from 4.8 per 1,000 to 2.2 per 1,000. The NICU is taking steps to reduce those errors even further.

Breast milk is viewed as medicine, says Dr. Oza-Frank, who is also principal investigator and research assistant professor of Pediatrics at The Ohio State University College of Medicine. Human milk is the best source of nutrition for preterm infants and reduces the incidence of necrotizing enterocolitis, respiratory tract infections and sepsis, while improving feeding tolerance and promoting cognitive development.

But giving babies wrong, expired or improperly prepared breast milk can cause harm.

The Nationwide Children’s NICU, which administers 6,000 breast milk feedings per month, began the QI initiative in 2008. The hospital fosters a blame-free environment that allows quality improvement issues to be honestly addressed.

At that time the project began, hand-written labels were used to identify milk bottles, nursing staff prepared and administered the milk and the NICU lacked a space to thaw, prepare and warm the bottles.

The QI team created a flow chart of the process of collecting, storing and administrating breast milk, examined policies and identified steps where the system failed. The team then updated and revised the process, which begins with a mother pumping breast milk at home or on site and ends with warming the bottle bedside just prior to feeding.

The QI team received approval from Nationwide Children’s administration to buy a barcoding system, which includes bedside scanners with 66 possible error codes. After an actual wrong-milk-to-wrong-infant error in 2011, full-time milk technicians were hired and a centralized milk room built.

Following full implementation of each of these changes, the number of scanned errors dropped significantly and voluntarily reported errors also declined from 58 in 2013 to 29 in 2015.

To try to further reduce milk preparation errors, the barcode system has been integrated with electronic health records. Milk technicians can now, for example, use one computer screen to read a fortification order and verify it with bar coding. The researchers will study the effect of this feature on error rates.

To ensure expired milk is properly disposed of and doesn’t remain a source of potential error, Nationwide Children’s is discussing with the system vendor how to track what happens to the bottle after scanning shows it’s expired.

After this study was started, the milk bank that supplies donated milk to Nationwide Children’s began using the same barcode system. This helps nurses to see when the milk was checked in, how long it was stored and other data needed to ensure donor milk meets the NICU’s standards and matches with the right baby. A future study will try to determine if donated milk yields a different set of errors that need to be addressed, says Dr. Oza-Frank.

As the NICU strives to improve milk safety, its breast milk committee seeks to increase breast milk feeding rates. In addition to six lactation consultants who cover the hospital, 13 members of the NICU staff are certified lactation consultants and 43 NICU RNs have additional lactation training, says Nationwide Children’s NICU Lactation Educator Stacy Notestine, RN, BSN, IBCLC. They provide mothers with education and support around the clock.


Oza-Frank R, Kachoria R, Dail J, Green J, Walls K, McLead, RE. A quality improvement project to decrease human milk errors in the NICU. Pediatrics. 2017 Feb;139(2).

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