Applying PPID safety standards to breast milk

102716ppidbabyinsideInformation Services (IS) collaborated with several partners to extend Positive Patient Identification (PPID) safety protocols to breast milk. Centers for Disease Control (CDC) guidelines say feeding a child expressed breast milk from a different mother should be treated as an accidental exposure to bodily fluids.

Holding breast milk delivery to the same identification standards as medications reduces the possibility of adverse events by ensuring the right milk goes to the right babies.

Why PPID is important

As an industry, health care strives continuously to accurately identify patients and access their correct medical records. At the heart of the issue is patient safety, as misidentification can result in serious medical errors. According to 2015 industry statistics, of every 10,000 attempts to access a patient record, 1,000 will result in a patient identification error and 60 will result in an adverse event.

PPID Milk Project Plan

IS partnered with nursing, Pharmacy, Milk Bank, Dietary and Clinical Informatics & Training to apply PPID safety protocols to breast milk. The PPID process incorporates barcoding using Rover, an Epic medication scanning solution, to positively match medications, blood products, lab results and now breast milk to the correct patient. It also documents any supplements added to milk or formula.

Epic establishes order sets and associated workflows governing the dispensing of milk to patients, and generates product labels to be scanned. This allows for nursing or other health care providers to complete a positive patient ID workflow to prevent a baby from being given expressed breast milk from the wrong mother.

PPID implementation

PPID for breast milk went live September 27, introducing to NICU caregivers a new feeding section within newborn order sets that include new feeding orders. New workflow features:

  • Nurses print barcode labels specific to the breast milk order and provide to mom to apply to containers of expressed breast milk, which is stored in the milk bank.
  • Modification orders (i.e. breast milk additives) are routed to the milk bank, which prepares the recipe and prints an order-specific label for the modified breast milk order, which is then delivered to the unit as normal.
  • At feeding time, a nurse scans baby’s armband and the barcode on the breast milk container. If the barcode matches with an active feeding order, the nurse will give the milk to mom to feed. When baby is done, the nurse will confirm and document the accurate volume intake.