KKH to implement all recommendations by committee in baby mix—up case

SINGAPORE: A Review Committee has come up with 15 recommendations to prevent another baby mix—up at KK Women’s and Children’s Hospital (KKH).

Two newborn babies were wrongly discharged to their mothers in an incident in November.

The measures involve tightening processes regarding identification of newborns, ward operations, the discharge process, and implementing new technology.

There will be two staff involved in the tagging and re—tagging of babies at all times. Parents will verify the baby’s particulars.

The way a baby is tagged will be refined to ensure that the tag does not drop off easily.

There will also be proper documentation for tracking the movement of babies in and out of the nursery.

At a media conference on Wednesday, Chief Executive Officer of KKH Professor Kenneth Kwek said the hospital has accepted all the recommendations made by the four—member committee, and they will be implemented by the end of next month.

Most of the recommendations made had already been acted on and implemented within a week of the incident.

The hospital will act on the remaining recommendations by the end of January.

Professor Kwek also said 17 people involved in the incident have been taken to task.

Three staff nurses directly involved in the mix—up have received disciplinary action. They received written warnings, were suspended from work for a week with no pay, and have been taken out of clinical duties for at least three months.

They will be closely supervised and their performance reviewed for at least six months.

Fourteen ward staff involved also received warnings or counselling.

Professor Kwek said the hospital extended an offer of compensation to the parents over and beyond the cost of their stay, but would not give further details.

He said the hospital is committed to preventing any repeat of the mistake.

Professor Kwek said: "The error should never have taken place. KKH has taken immediate measures to close gaps and ensure patient safety. Again, I would like to apologise to the parents. We will continue to tighten our processes and protocols, and ensure strict compliance."

The committee noted that the mix—up was triggered when the babies were placed in wrong cots. This resulted in a wrong identification tag being applied to one baby.

KKH earlier said the incident came to light when one of the parents noticed that the baby taken home wore an identification tag belonging to another mother.

The hospital suspected that checks were not carried out properly when the baby was being discharged. The other baby was with the wrong parents for about 10 hours.

Parents welcomed the ramped—up measures.

Madam Nahidah Begum, a 47—year—old teacher, said: "Of course it’s a good idea because as a parent I would feel very assured if I know I’m going back with the right child."

Ms Grace Ng, a 44—year—old customer service specialist, said: "They have a good idea to have the father move along with the baby to make sure it’s tagged correctly... that will be good enough."

Ms Nur Syafika, a 21—year—old housewife, said: "It’s important because we are the ones who give birth to the baby, so we need to see our real baby. So if this system is improved, I don’t think this kind of thing will happen again."

The Ministry of Health said the lapse by KK Women’s and Children’s Hospital (KKH) in not safeguarding and ensuring patient safety was unacceptable.

It said the lapse revealed that more work needs to be done to root and reinforce the culture of safety across the organisation and in all of its activities.

The Ministry’s statement came after a Review Committee tasked to look into the recent incident where two babies were discharged to the wrong parents found that the mix—up was due to a lack of compliance with established procedures.

MOH has written a stern letter to the CEO of KKH to register its disappointment and concern on the lack of supervision and oversight, especially with regard to patient identity and safety in the nursery.

It has also directed the Chairman of KKH’s Patient’s Safety Council to step up the council’s oversight of ensuring patient safety and compliance by the staff.

MOH said KKH’s leadership will need to take all necessary steps to close gaps and to make improvements including conducting periodic audits to check for compliance.

The Review Committee was chaired by Professor Ho Lai Yun, Senior Consultant of the Department of Neonatal and Developmental Medicine at the Singapore General Hospital.

— CNA/de