3 Other Baby Mix-Ups Disclosed at St. Joseph

Officials at St. Joseph Hospital, which sent a newborn home with the wrong family last Sunday, disclosed Friday three other infant mix-ups, ranging from an apparently minor incident to a case in which the wrong mother breast-fed a baby for 30 minutes.

Though none of the babies in the newly revealed cases left the hospital with the wrong parents, the pattern of mix-ups may compound problems for the hospital, which fired two nurses involved in last Sunday’s switch.

The hospital also is under scrutiny by the California Department of Health Services. And it has asked the Joint Commission on Accreditation of Healthcare Organizations to look into Sunday’s incident, in which the hospital released an infant to the wrong couple, who took the child home. The couple was notified of the error about 90 minutes later and returned to the hospital with the infant.

Valerie Orleans, a spokeswoman for the Orange-based hospital, said that was the first time in the hospital’s 70-year history that a baby had been released to the wrong parents.

However, the pattern of mix-ups stretches at least to June.

A couple interviewed by The Times said Friday that a nurse mistakenly gave their baby to another mother, who breast-fed the infant. They said St. Joseph assured them last summer that new policies were adopted to prevent such switches.

“First of all, they didn’t correct their actions,” the boy’s 30-year-old father said, referring to last Sunday’s switch. “And, second, when this thing happened [Sunday], they didn’t admit they had had problems in the past.”

While confirming the June incident, a hospital official took pains Friday to distinguish between the two situations.

“I can understand their being upset, absolutely,” Katie Skelton, vice president of patient care services said about the June switch. “What’s different [about Sunday’s incident] is that it wasn’t one error, it was a series of errors and the baby got discharged. That, clearly, we’ve never had any exposure to.”

In last June’s incident, a nurse brought two babies into a room shared by two women, according to a hospital official and the parents of one of the infants. A nurse, momentarily distracted, gave the wrong babies, both boys, to the women.

One of the mothers breast-fed the wrong baby for 30 minutes, realizing the mix-up only when she stopped to change the infant. Her son was not circumcised, but this baby was.

Neither set of parents wants to be identified, but the mother whose son was mistakenly breast-fed is reluctant to criticize the hospital, which she lauded for its all-around care.

However, she said, the early-morning mix-up greatly upset her because of the exchange of bodily fluids from another woman to her son. That fear proved unfounded, but even hospital officials acknowledged the seriousness of the switch, the boy’s mother, 28, said.

“The doctor came in and said, ‘This could have been a train wreck, and it ended up being a inor fender-bender.”

The couple said they met with a number of hospital administrators after the mix-up and were assured steps would be taken to ensure it never happened again.

The mother said she doesn’t see a great distinction between mistakenly breast-feeding the wrong baby and leaving the hospital with the wrong baby.

“To me, going home with the wrong baby and being switched in the hospital, it’s all the same,” she said. “The doctors tried to tell me, ‘There used to be wet nurses.’ I said, ‘Fine, if that’s what they picked. That’s not what I picked.’ ”

Since last June, Skelton said, changes were enacted, including a ban on nurses taking two babies at a time to a shared room. In addition, nurses must not only read the infant’s wrist identification numbers out loud, they also must double-check the mother’s wrist ID to ensure a match, she said.

The changes, however, didn’t prevent two mix-ups since then, Skelton acknowledged.

In August, a newborn was put in the wrong bassinet after circumcision. A nurse caught the error and corrected it before the baby was brought to his mother’s room, Skelton said.

Several weeks ago, she said, a nurse walked into a mother’s room with an infant, only to have the mother immediately realize that the baby was not hers. The nurse, who never gave the infant to the woman, quickly turned around and left the room with the child.

Times staff writer Liz Seymour contributed to this report. Parsons is a columnist on the Times’ Orange County staff.