Agency Calls for Extended Investigation of Baby Mix-Up

The nation’s largest hospital accreditation agency has asked St. Joseph Hospital of Orange to conduct a more exhaustive investigation into the mix-up last Sunday that sent a newborn baby home with the wrong parents.

The hospital fired two nurses Wednesday and released a written statement saying that it had concluded its investigation of the incident.

But the Joint Commission on Accreditation of Healthcare Organizations said the hospital needs to go further than to say, as it has this week, that the mix-up was an isolated incident caused by a couple of employees.

“Very often, we human beings think we can follow through on something by blaming somebody and firing somebody and getting rid of them, but that’s usually not the entire answer,” said Julie Roberts, a spokeswoman for the commission. “It’s important to look at the systems and processes, so we’re asking them to dig down real deep and keep asking why this happened.”

The mistake falls into a category the organization considers “sentinel events,” extremely serious occurrences that range from a patient’s permanent loss of function because of hospital error to the abduction or erroneous discharge of a baby.

The commission, based in Chicago, tracks mistakes such as the one at St. Joseph and seeks to determine whether they are the result of patterns in hospital management or are isolated incidents.

On Thursday, Katie Skelton, vice president of patient care services and chief nurse executive, said that despite its earlier statement, the hospital is planning to conduct a deeper investigation. It had only completed its scrutiny of the nurses, she said.