A Quality Improvement Project to Decrease Human Milk Errors in the NICU

Pediatrics. 2017 Feb;139(2):e20154451. doi: 10.1542/peds.2015-4451. Epub 2017 Jan 11.


Backgroud and objective: Ensuring safe human milk in the NICU is a complex process with many potential points for error, of which one of the most serious is administration of the wrong milk to the wrong infant. Our objective was to describe a quality improvement initiative that was associated with a reduction in human milk administration errors identified over a 6-year period in a typical, large NICU setting.

Methods: We employed a quasi-experimental time series quality improvement initiative by using tools from the model for improvement, Six Sigma methodology, and evidence-based interventions. Scanned errors were identified from the human milk barcode medication administration system. Scanned errors of interest were wrong-milk-to-wrong-infant, expired-milk, or preparation errors. The scanned error rate and the impact of additional improvement interventions from 2009 to 2015 were monitored by using statistical process control charts.

Results: From 2009 to 2015, the total number of errors scanned declined from 97.1 per 1000 bottles to 10.8. Specifically, the number of expired milk error scans declined from 84.0 per 1000 bottles to 8.9. The number of preparation errors (4.8 per 1000 bottles to 2.2) and wrong-milk-to-wrong-infant errors scanned (8.3 per 1000 bottles to 2.0) also declined.

Conclusions: By reducing the number of errors scanned, the number of opportunities for errors also decreased. Interventions that likely had the greatest impact on reducing the number of scanned errors included installation of bedside (versus centralized) scanners and dedicated staff to handle milk.

MeSH terms

  • Bottle Feeding*
  • Hospitals, Pediatric
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal*
  • Medical Errors / prevention & control*
  • Medication Systems, Hospital
  • Milk, Human*
  • Ohio
  • Quality Improvement / organization & administration*
  • Risk Management / organization & administration