The End Of An Error
Understanding and Preventing Errors in NICU Infant Feeding Management
This three-part series explores how understanding the root causes of mistakes in infant feeding management can help prevent them in the NICU. Originally published in Neonatal Intensive Care, The Journal of Perinatology-Neonatology: Part 1 (page 38), Part 2 (46), and Part 3 (40).
Part 1: Introduction
The NICU is an intense and complex clinical environment, dealing with the most precious patients. This complexity presents many opportunities for error, particularly in infant feeding management.
Currently, there are no universally accepted national standards for regulating safety management in the preparation and administration of infant feedings in hospitals. The available literature on feeding management is limited compared to other healthcare topics, often focusing on the dangers of errors, such as infection risks and HIPAA violations. While important, I prefer to examine the root causes of these errors.
Few studies have conducted a Failure Mode and Effects Analysis (FMEA) for infant feeding management, identifying 32-282 potential failure modes requiring human detection and prevention (see Steele and Oza-Frank). A recent Six Sigma study estimated the risk for breast milk error at 1 in 10,000 feeds, a predictive model based on blood transfusion error rates (see Luton).
Specific errors include feeding an infant the wrong milk, expired milk, and errors in milk preparation, all with significant consequences. This series will cover the reasons for errors and mitigation strategies. Part 1 focuses on cognitive behaviors, human factors, and electronic management opportunities to improve safety.
Cognitive Demands
Errors occur due to cognitive reasons, including distractions, prospective memory, cognitive fatigue, inattentional blindness, and mental validations.
Distractions in healthcare are well-documented, increasing medication error risk by 12.7% with each interruption (Westbrook). While no studies specifically address interruptions during infant feeding preparation, similar disruptions occur.
Interruptions impair prospective memory, the ability to remember deferred tasks (see ISMP, and Relihan). If a signal to complete a task is missed, errors can occur. For example, a nurse interrupted during feed preparation may forget to return to the task, risking omissions or duplications.
Inattentional blindness, or perceptual blindness, occurs when the brain fails to see an object or detail when attention is not fully focused. This can lead to errors in patient or medication identification.
Mental Validation
An FMEA at a large urban hospital found 15-20 mental validations are required to prepare feedings for one infant. NICU nurses may prepare 12 feeds in a shift, requiring over 180 mental validations, increasing error potential.
Conclusion
Infant-specific recipe management is gaining momentum, but infant feeding management remains complex. With intricate recipes and feeding regimens, we must handle the workload safely. Human detection and prevention of failure points are crucial, considering cognitive failures and mental validations.
Part 2 will explore human factors influencing errors and operational factors affecting feeding management.
Part 2: Introduction
Part 1 covered cognitive behaviors contributing to errors. Part 2 of "The End of an Error" explores human factors and operational factors influencing feeding management errors.
Human Factors
Normalization of deviance, or operational deviance, describes how unacceptable practices become acceptable over time (see Banja). Workarounds often arise when staff lack the right tools or processes, leading to errors.
Nurses naturally create workarounds when faced with workflow inefficiencies. An article titled "The Normalization of Deviance in Healthcare Delivery" discusses active and latent errors (see Banja). Latent errors occur when systemic issues allow active errors to become accepted, perpetuating deviance.
Error Identification
Root causes of errors are multifactorial. FMEA studies have identified 32-282 potential failure modes in infant feeding management (see Steele and Oza-Frank). Differences in workflows and resources across institutions impact error potential.
Contributing Factors
NICU staff face workflow challenges and operational errors. The bottle lifecycle is complex, with many hands and state changes involved.
Figure X
Bottle Pathway in Figure Y – a further development of the life cycle. In its simplest iteration, it is still a highly complex process. Though the set up may be different and various staff could own separate parts of this process, every institution experiences this. With this level of complexity, and considering everything that has been discussed, it would be foolish to not expect errors.
Figure Y
Storage and Transport – Practically every institution faces challenges regarding a lack of ample storage for maternal and donor milk. Some institutions are forced to limit the amount a family can store at the hospital.
Many freezers have bins with open lids (either because they are too full or the lids have long since disappeared). Patient bins may be poorly labeled or, worse, not labeled at all. Milk bottles are placed directly on the shelves or have fallen out of the container. How can a safe process be maintained under these conditions?
Bottles are then transferred from home to the hospital. Milk is received, stored, prepared, and delivered. Refer back to Figure X and Figure Y for the physical movement of a bottle.
Handwritten Labels
In many situations, mothers handwrite the date and time pumped on labels. One study showed that 18% of errors stemmed from handwritten labels, including incorrect information and illegible handwriting. Staff must then manage the entire process from this point. If they start with incorrect information, how can the process be executed accurately and safely?
Manual System Entry
Institutions using scanning systems that require manual data entry face opportunities for error through transcription mistakes, incorrect, or incomplete data.
Patient Identification Challenges
Unique naming is complicated in the neonatal population, especially with multiples. The new Joint Commission requirement for infant naming conventions has improved this issue, but challenges persist.
Conclusion
We've identified failure points in feeding management, many of which go undetected, unappreciated, unreported, and unresolved. The true breadth of these issues is not fully realized.
Part 3: Introduction
Part 1 of “The End of an Error” covered cognitive failures and mental validations impacting error potential. Part 2 focused on human factors influencing processes and contributing to errors, detailing some failure points. Part 3 discusses the current state of electronic management of infant feeding and opportunities to improve safety.
Baby-Bottle Scan Insufficiency
Many institutions employ EMRs that treat breast milk as medication to check the safety box. While philosophically and clinically true, this approach lacks in safety management. Most EMRs use existing medication management systems as a proxy for infant feeding safety scanning. While better than nothing, these systems often require infant feeding orders to be built as medication orders, which do not accommodate complex recipes and feeding regimens.
These systems provide final confirmation of a baby-to-bottle match during feeding but miss other preparatory steps, creating a false sense of security for families and staff.
Processes Missed:
Patient verification
EBM/DHM state change rules
Recipe calculations and verification
Expiration verifications
Feeding order validation at administration
Leadership Challenges
What steps can we take to change the culture around feeding management safety? How do we as leaders help others understand these issues need attention?
Establish a Culture of Safety: Safe communication is key. Oversight and monitoring for rule compliance are essential, even if difficult.
Validation of Need: Conduct institutional FMEA, process mapping, and error rate evaluations. Publish findings to validate issues.
Consensus: Collaborate with data in hand to establish standards of care and best practices.
Research: Conduct and publish research to start conversations and raise awareness.
Conclusion
The conversation around errors and our ability to detect and prevent them is complex. We've explored cognitive reasons for errors, such as distractions, prospective memory, cognitive fatigue, inattentional blindness, and mental validations. We've also examined normalization of deviance, active and latent errors, and operational challenges.
Currently, no universally accepted national guidelines regulate the safety management of infant feeding preparation and administration in hospitals. While there are governing bodies for medication safety, donor milk treatment, enteral nutrition safety, and more, infant feeding safety lacks ownership. It is up to clinical and administrative leaders invested in improving infant feeding safety to lead the charge.