The unintended consequences of being friendly: a case study.
Baby-friendly certification recognizes hospitals that promote early physical bonding between mother and infant, immediately after birth. Most births can accomplish physical bonding without increased risk to mother or infant. When mother or infant have complications and each have intravenous (i.v.) lines and are receiving medications, the physical bonding post-birth may also inadvertently put the patients at risk. A baby-friendly community hospital in New England found that early bonding put an infant at higher risk for medication error when the two i.v. lines were not properly identified and the infant received a medication intended for the mother. The growing body of literature on i.v. medication safety does not address this particular type of error, and this was an error that technology would not have prevented. The "5 rights" of medication safety are not as effective as physical separation of the two individuals during medication administration. A brief separation does not diminish bonding, and the practice has prevented subsequent errors.
Cooper
Mary Reich
MR
Warren Alpert Medical School, Brown University, Providence, RI, USA. mcooper@lifespan.org
Duquette
Cathy E
CE
McWilliams
Terrence
T
Orsini
Michael
M
Klein
Arthur A
AA
D005260:Female; D006764:Hospitals, Community; D006801:Humans; D007231:Infant, Newborn; D007262:Infusions, Intravenous; D008508:Medication Errors / Q000517:prevention & control*; D009034:Mother-Child Relations; D009511:New England; D009769:Object Attachment; D009775:Obstetrics and Gynecology Department, Hospital / Q000592:standards*; D019982:Organizational Case Studies