Baby swap in Singapore: The aftermath

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The baby swap that happened last November has raised concern about the baby discharge process. Find out how the management at KK Women's and Children's Hospital has done to ensure such a thing does not happen again.

Sleeping newborn baby in hospital cot

KKH’s infamous baby swap incident in Singapore

The baby swapping saga has raised questions as to the safety measures in place in hospitals during the baby discharge procedure.

In the aftermath of the hoo-ha and public outcry and their own internal investigations, the KK Women’s and Children’s Hospital (KKH) has pinpointed the reasons that led to this unfortunate and embarrassing incident.

According to reports in Asiaone, it would seem that human negligence and complacency were the key reasons for this lapse and KKH have gone on to discipline all staff directly involved in the situation.

How it happened?
According to KKH at a media conference, the incident was triggered by a series of human errors, including placing the two babies in the wrong cots as well as giving them the wrong identification tags and subsequently not checking the babies’ ankle identification tags during the discharge process. The errors occurred because the personnel had not adhered to protocol and had displayed an attitude of complacency.

According to Professor Kenneth Kwek, KKH’s chief executive, after he spoke to the affected staff he got the sense that they had felt that as there were many layers of checks and thus did not think that anything would go wrong. So, they felt that it was not so essential to do checks on their end.


Personnel disciplined
The hospital has gone on to discipline the three nurses who were directly involved in the incident, as well as their two supervisors. Besides those directly involved, KKH has also counselled and given warnings to the staff working in the ward where the mix-up occurred. In total, 17 staff have been taken to task since the incident happened.

Checks essential
The message that Professor Kwek reiterated during the conference was that “When it comes to patient identification and patient care, you must be accountable for your own actions [and] not rely on your colleagues.”

New measures
To prevent such a thing from happening again, KKh has stepped up and tightened its measures when it comes to the discharge and baby tagging process.

For instance, for the tagging and retagging of babies, two staff have to be involved, one of whom needs to be a registered nurse. Any replacement of dislodged tags has to be properly documented in all clinical notes from now on as well as the documenting all movement of babies in and out of the nursery.

The cards used for babies’ cots will also be redesigned to reflect only important information such as the mother’s name and identification number. These cards will be used from next month onwards.

With regards to the discharge process, both the nursery and the ward staff will be involved in discharging the baby to the mother, so there is always another person or authority to double check the discharge.

Will this be enough?
Whether these new measures will be enough to restore people’s faith in the premier women’s and children’s clinic remains to be seen but it reminds us once again how important it is for us, the parents to also be vigilant in situations such as these.

Don’t forget that it was due to the vigilance of the parents involved that led to the alarm being raised and the two babies safely returned to their real parents before further damage could be done.

 


 

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