Use of the Six Sigma Methodology to Reduce Incidence of Breast Milk Administration Errors in the NICU

Abstract

Breast milk is the optimal source of nutrition for infants. According to research, neonates fed breast milk have a reduced risk of sepsis, increased feeding tolerance, a decreased incidence of necrotizing enterocolitis, and better neurodevelopmental outcomes. Unfortunately, researchers have not identified practices to reduce or eliminate the risk for errors in breast milk administration. This article discusses the potential hazards of incorrect administration of breast milk. It then describes how the tertiary care center at Children's Hospital of Illinois implemented a policy utilizing six sigma quality improvement methodologies to improve breast milk administration. Since implementation of this policy, the NICU at our hospital has reduced the risk of breast milk administration errors to less than 3.4 mistakes per million opportunities.

The role of critical incident monitoring in detection and prevention of human breast milk confusions

“…Drenckpohl et al [5] described a remarkable and Dougherty and Giles [4] a transient reduction of breast milk administration errors after focused interventions. While Drenckpohl et al used the six sigma methodology to monitor and reduce the incidence of breast milk application errors, Dougherty and Giles developed a quality assurance (QA) program.…”

“…Breast milk, the optimal source of nutrition for neonates, may contain pathogens and therefore carries the risk to transmit infections [4,5]. Namely, the human immunodeficiency virus, hepatitis virus, cytomegalovirus, herpes simplex virus, and methicillin-resistant Staphylococcus aureus can have harmful consequences for the neonate [9,11].…”

“…Namely, the human immunodeficiency virus, hepatitis virus, cytomegalovirus, herpes simplex virus, and methicillin-resistant Staphylococcus aureus can have harmful consequences for the neonate [9,11]. In addition to this genuine medical problem, breast milk administration error produces enormous psychic stress to the mother whose baby received the milk of another woman [5]. Recently, a breast milk administration error led to a headline in the yellow press in Switzerland, which also shows the relevance of this misidentification error in the public [6].…”

Centralized Model of Human Milk Preparation and Storage in a State-of-the-Art Human Milk Lab

“…[14][15][16][17] Potentially adverse outcomes may result from improperly labeled milk, unsuitable storage conditions, unsafe milk preparation, incorrectly fortified milk, and misadministration of human milk. 18,19 Drenckpohl et al 20 identified inconsistencies in the process for managing human milk storage, preparation, and distribution resulting in "Centralized handling of human milk is an important strategy to provide optimal quality care to patients and to assure safety in storage, preparation, and distribution of human milk for hospitalized infants. "…”

Pediatric Aspects of Inpatient Health Information Technology Systems

“…75,76 In addition to system design to prevent such errors, barcoding systems have been developed, explored, and advocated 77 as a means of tracking and ensuring correct administration of human milk.…”