Hospital Chief Apologizes for Mix-Up of 2 Babies

The mix-up of two newborns at St. Joseph Hospital in Orange was the result of a series of errors thought to have begun when the infant boys were placed in the wrong bassinets, and their true identity then repeatedly overlooked, officials conceded Monday.

It is the kind of mistake that is never supposed to happen, the kind of mistake that is every new parent’s nightmare. This one has already caused the hospital to begin an investigation and change its policies.

At St. Joseph, newborns are fitted with bracelets that carry their names and unique identification numbers, a system that is routine at many hospitals. Parents are given matching bracelets and hospital staff is charged with double-checking the numbers to make sure they are the same whenever an infant is handed over to a nursing mother, or placed back in a bassinet that also carries an identification tag.

But all the precautions failed Sunday when one baby was sent home with the wrong parents. The mix-up was only discovered after the other mother, who had remained in the hospital, realized she had breast-fed the wrong baby.

Hospital President Larry Ainsworth apologized Monday for the “regrettable” situation that he blamed on human error and conceded that the mix-up involved two baby boys who are “entirely different in their last names.”

To confirm that the babies are now correctly placed with their parents, the hospital conducted antibody tests that match mother and child. Because both mothers had breast-fed the wrong children, hospital officials also tested the babies and their parents for hepatitis B and HIV, which can be passed via mother’s milk. Those test results will be given to the parents within the week, officials said.

Iliana Bravo and Brian Lambert of Tustin, who went home Sunday with the newborn they mistakenly believed to be their 3-day-old son, Aaron Alexander Lambert, said they are relieved they have the right baby.

“I just thank God it’s over. We’re going to try to forget this and move on,” said Bravo. “It’s 100% our baby. . . . He looks like his father.”

The other parents, who have asked not to be identified, have also left the hospital after being reunited with their child, who was born Thursday.

Four nurses who had direct contact with the infants have been placed on temporary leave. Some were questioned Monday, and more interviews will be conducted today as part of the hospital’s investigation, said Ainsworth.

Effective immediately, the hospital has modified patient checkout procedures to prevent a similar mistake, Ainsworth said. The hospital will require two nurses and the mother to double-check information before discharging newborns.

“All of us who are parents know this is a very frightening circumstance,” Ainsworth said. “[We] feel very badly about this.”

Newborns are removed from their bassinets several times a day to be fed, weighed and bathed. Perhaps, Ainsworth said, the babies were inadvertently switched during those rounds.

Ainsworth said the hospital staff later erred when Bravo and Lambert left with the wrong child. Hospital policy requires that the identification wristbands of the mother and child be clipped and attached to their release form.

A nurse is charged with verifying that the tags match and requiring the parents to sign the form to further double-check that a child is being discharged with his or her biological parents. In this case, however, the mismatched wrist bracelets were overlooked.

“[The Lamberts’] form was all nicely filled out, but the problem was that the baby’s name [on the bracelet] was clearly different from the mother’s name,” Ainsworth said. “It seems to me that neither the nurse nor the mother took a close look at the ID bracelets.”

Meanwhile, Aaron was mistakenly given to and fed by another new mother who remained at St. Joseph Hospital. This mother eventually noticed the discrepancy on Aaron’s wristband and alerted hospital authorities.

Having already arrived home from the hospital, Bravo breast-fed the baby she thought was hers and was resting when hospital officials called.

“I was [like], ‘What? What are you talking about?’ ” Bravo said, adding that hospital officials told her “You need to come right away.”

Brian Lambert on Monday blasted hospital officials for the mistake. He said he didn’t pay close attention to the names on the form because “They just said, ‘Sign here,’ and so I did.”

Administrators at several hospitals said the high-profile incident may cause facilities nationwide to review their procedures for discharging newborns.

Hospitals install what are thought to be fail-safe systems in which the identity of newborns is constantly monitored by doctors, nurses, hospital staff and parents alike.

About 4 million babies are born in the United States each year, but “switches” have occurred in only a handful of cases.

Contributing to this report was Times staff writer Tini Tran.