St. Joseph Told to Probe Deeper Into Switch of Infants

The nation’s largest hospital accreditation agency has told 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 says 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 a 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 due to 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. It has reviewed 13 similar cases since 1995, but its figures are based on information hospitals choose to reveal about themselves or to report their own errors.

“Something like this is very serious, and what we require them to do is to conduct a root-cause analysis,” Roberts said.

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

The mix-up of two newborns is believed to have begun when the infant boys were placed in the wrong bassinets.

As a result, Iliana Bravo and Brian Lambert of Tustin went home with a child they mistakenly believed to be their son, Aaron Alexander.

After the mistake was realized and rectified, the hospital suspended four nurses who had significant contact with the infant and on Wednesday, fired two of them, retaining the other two.

“All four people had varying levels of involvement,” Skelton said, “but we looked at each one individually so as not to have a knee-jerk reaction and fire them all because of the notoriety of the situation.”

At St. Joseph, newborns are fitted with bracelets that carry their names and identification numbers. Parents wear matching bracelets, and the hospital staff is charged with double-checking the numbers to make sure they are identical whenever an infant is either brought to or removed from its mother’s side.

Finding the root of the errors made, however, will be far less simple to do, she said. “It really takes a large cross-section of people to determine all the factors,” she said.