A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been exclusively breastfed since the time of his birth.
In light of the difficulties associated with regular breastfeeding in the hospital, the mother stored her pumped breast milk in the refrigerator on the infant's ward in the hospital. At the time of the first feeding, a nurse's aide retrieved a bottle from the refrigerator, a bottle labeled only with the mother's room number and two initials. Approximately 5 minutes later, after giving the child 15 mL of the breast milk, the mother noticed that the initials on the bottle were not those of her son and called a staff member to the room, who promptly involved the child's main nurse.
The nurse and nurse's aide reviewed the events and suggested to the mother that the administered milk might, in fact, be hers—despite the fact that the initials on the bottle were not those of her child. Upon further review, it was noted that the initials matched those of the nurse's aide who separated the original milk container into small feeding bottles. The mother, skeptical that the milk was hers, asked that the nurses search the refrigerator. There, they found another bottle, labeled with the room number and the child's initials, that clearly was the mother's milk. In other words, they confirmed that the patient had unquestionably received 15 mL of the wrong human milk.
On further investigation, they learned that the mistaken milk sample actually belonged to the patient who previously occupied that room. Although that patient had since been discharged, the breast milk remained in the refrigerator. An infectious diseases consult subsequently counseled the family regarding potential risks from using the wrong breast milk. Additional laboratory testing revealed that no infectious transmission had occurred, and no other objective harm was identified by the time of discharge.
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