Baby switch plagues VA facility - three years later
'Weight discrepancy should have raised red flag'
While good newborn security practices were in place three years ago at the University of Virginia Medical Center (UVMC) in Charlottesville, the facility has implemented improvements since then as an ongoing part of its activities. Now, in the light of a baby-switch case, UVMC is improving its newborn security processes even further.
Two girls born three years ago at 644-bed UVMC were switched at birth. It wasn't until DNA tests were performed in June as part of a child-support case that it became evident that one of the women was not the biological mother of the child she took home. UVMC voluntarily reported this occurrence to the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, as soon as it was discovered, and a root-cause analysis is in progress.
The medical center reviewed its records "with a fine-tooth comb," according to a statement on the baby switch, and remains confident that good newborn procedures and policies were in place and were carried out. Thomas A. Massaro, MD, UVMC's chief of staff, stated that Paula Johnson's baby was banded within minutes of delivery in the delivery room. Banding was documented, and the documentation was later corroborated in the medical record.
Steps taken: Video cameras, delayed egress
Marguerite Beck, a spokesperson for UVMC, says two new security measures will be in place by the end of autumn - video cameras throughout the newborn and maternity areas, and delayed egress doors. The cameras will record the area continuously and transmit pictures to monitoring screens in the hospital security department. The delayed egress doors will sound an alarm for 15 seconds, during which time the staff can check to see who is exiting. "The delayed egress feature will be on the doors that must remain unlocked due to fire codes," says Beck.
But George Stevens, associate director of the Joint Commission's department of standards, disagrees that any doors in the newborn area cannot stay locked: "In areas of high security concern, doors may be locked as long as the staff is always in attendance and is trained to unlock them in the event of fire. Or a delayed lock can be put in place - it unlocks after a brief time but gives the staff a chance to apprehend someone trying to exit."
"Those measures were part of a plan for this year," explains Beck, "but in light of this case, we've accelerated the pace of implementation."
It had been UVMC's policy for the staff member who put identification bracelets on mother and baby to make a notation on medical records saying "Bands applied" and including the date and time and name of the person doing it. Now, the record is more specific - additional information is included indicating where the bands are applied (baby's left arm, for example).
And the facility is not stopping there. "A task force has been appointed to look into what other hospitals are doing to ascertain what new security technology works and what doesn't," says Beck.
UVMC first heard of the incident when the lawyer for Johnson called to say his client's DNA did not match that of her baby. The hospital immediately conducted an internal review. "A team went over the medical records for several days," says Beck, "to see what happened and to see who the second child was. This was a three-year-old case." Doctors, nurses, and administrators could find no evidence of a break in service. All the appropriate notations were there, she says. Without evidence in the internal review that it was an accident, they turned the matter over to the police. "We want to find out what happened," says Beck. University and state law enforcement officials are investigating the matter.
Hospital spokespersons say an inadvertent mix-up is virtually impossible because of procedures used to ensure the identity of baby and mother moments after birth. For 24 years, they say, identification bracelets bearing one number have been placed on mother and baby in the delivery room, then noted at discharge. However, newspaper articles have reported that Johnson stated that the bracelets around the wrist and ankle of the infant she took home were so loose they could easily slip off. She asserts that neither she nor her newborn were fitted with matching identification bracelets in the delivery room. Newspapers also reported that a videotape taken of the switched baby and her mother a few hours after delivery shows a bracelet lying next to the baby on the bed.
"What nurses typically do when they apply bands is put their own finger between the band and the baby's arm," says Beck. "You don't want it too tight or it will cut off circulation. But it has to be secure, so we're looking at all these measures."
Massaro said in a statement that the weight difference between the girls should have raised a red flag for parents and staff alike. On June 29, 1995, Johnson gave birth to a 9-pound, 6-ounce girl. When she left the hospital three days later, the baby she thought to be her daughter weighed 7 pounds, 12 ounces.
One day after Johnson learned the results of the blood DNA tests, the parents of the daughter she thought was hers were killed in a car crash, complicating matters considerably. The remaining family members have decided that the two 3-year-old girls will grow up as sisters in an extended family forged from the incident. Although it appears the baby-switch will have as agreeable an ending as could be expected, the families have not ruled out a lawsuit against UVMC.
Four million babies are born in the United States each year. The Joint Commission has recorded three instances of baby switching and seven abductions in the past four months. As of mid-July this year, the National Center for Missing and Exploited Children in Arlington, VA, has recorded 178 baby abductions since 1983, half of which were taken from the mother's room. Thirteen are still missing.
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