1. Huber, Charlotte MSN, RN
  2. Blanco, Mary E. MSN, RN
  3. Davis, Monica M. MSN, MBA, CRNP


The Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced PAY-sirs) is a confidential, statewide reporting system on the Internet to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, were required to file information on medical errors beginning in June 2004.


Safety Monitor, this column in AJN from PA-PSRS, informs nurses on issues that can affect patient safety and presents strategies they can integrate easily into practice.


For more information on PA-PSRS, visit the Web site of Pennsylvania's Patient Safety Authority, at For the original articles discussed in this column or for other articles on patient safety, click on "Advisories and Related Resources" in the left-hand navigation menu.


This is a periodic column from the Pennsylvania Patient Safety Reporting System.


Article Content

Breast milk provides the best nutrition for newborns, conferring benefits of immunity, healthy development, and psychological and social well-being; it also contributes to the economic stability of families.1 A 2006 prospective study indicates that feeding breast milk to very-low-birth-weight infants improves their "cognitive skills and behavior ratings" and could even reduce the need for special education later in life.2 Newborns also receive their mothers' antibodies in breast milk, which may provide protection from infectious diseases. But breast milk can carry bloodborne pathogens, and therefore it may transmit disease when ingested.1, 3 Mothers are encouraged to breastfeed their infants because the advantages of breastfeeding far outweigh infection risks. HIV-positive mothers are urged not to breastfeed their infants, particularly if an alternative is available.4


The risks involved in managing a mother's expressed breast milk increase when mothers and infants are separated in patient care areas. Ensuring consistent delivery of the correct breast milk, which has been pumped and stored, to the correct infant is a challenge.3


By 2007 the Pennsylvania Patient Safety Reporting System (PA-PSRS, pronounced PAY-sirs) had received more than 30 reports of events involving breast milk. Of these, about 20 reports indicated that an infant received another mother's expressed milk. Problems identified included bottle labeling, patient identification, and refrigeration and freezing issues. The following cases illustrate these problems:


* A nurse inadvertently removed the wrong breast milk from the refrigerator. The mother started to feed her infant when she noticed the label on the bottle. The mother brought the mistake to the nurse's attention, but the infant had already received 5 mL of the wrong breast milk. The NP was informed of the error, and HIV testing was performed on the mother whose milk the baby received. Results were negative.


* During finger feeding (a method used for premature infants unable to latch onto the breast), it was discovered that an infant was receiving breast milk intended for another. The infant received roughly 15 mL of the wrong breast milk.


* After an infant received two feedings of breast milk from a bottle labeled with the baby's name, the mother reported that she hadn't expressed any breast milk. Investigation revealed that the bottle had been mislabeled.


* A refrigerator used to store breast milk was found not to be working; the milk was warm, although the temperature of the refrigerator had been checked daily and recorded as being within the appropriate range. All stored breast milk was discarded, and a new refrigerator was purchased.




Here are some suggestions to ensure breast milk safety at your hospital.


Infant and mother identification.


* Avoid separating infants from their mothers unless clinically necessary. When infants and mothers are separated, implement a highly reliable, organization-specific identification process.3


* Maintain infant identification as outlined by your organization.


* Make sure that the information on infants' and mothers' identification bands is complete and legible.


* Educate parents on the importance of frequently checking their baby's identification bands.3



Labeling breast milk containers.


* Label all breast milk containers consistently, correctly, and clearly, using moisture-resistant ink.3


* Include the infant's and mother's names on the label, as well as the infant's medical record number, the date and time the milk was expressed, and the date and time the milk was thawed.3


* Provide the mother with an empty breast milk container and completed label at the time she is expressing her milk. Show her how to document the date and time the milk was expressed on the label and how to immediately apply the label to the container so that all information is visible when opening the container.


* Inspect the label for accuracy, legibility, and completeness of information before storing the container.3



Storage and management.


* Establish a separate, designated area for both refrigerator and freezer for storing breast milk.


* Within the refrigerator and freezer, allocate a separate area for each infant's labeled container.3


* Store refrigerated breast milk at 35[degrees]F to 40[degrees]F (2[degrees]C to 4[degrees]C), and use or freeze within 48 hours.5 Store frozen breast milk at -4[degrees]F to 0[degrees]F (-20[degrees]C to -18[degrees]C), and use it within three months.5 (Organizational temperature guidelines may vary slightly.) Maintain a log of refrigerator and freezer temperature checks every shift.3


* Install alarms that are programmed to sound if there is an unacceptable temperature change.





* Maintain a current log with the mother's name and the date and time the breast milk was expressed. Document carefully when dispensing the milk for the infant.


* Verify with the mother that the breast milk container label matches the mother's and baby's identification bands.



Education and communication.


* Provide ongoing educational opportunities for staff to learn and demonstrate the correct handling of breast milk.


* Develop a process to ensure competency of all floating, agency, and temporary staff.3


* Give patients verbal and written information on the collection, labeling, storage, and dispensing processes for breast milk, paying close attention to any individual cultural, language, or literacy barriers.


* Elicit the assistance of your organization's breastfeeding specialist.





* If an infant receives the wrong expressed breast milk, minimize the infant's risk of exposure to pathogens. First, understand the risks involved, and then follow the standard plan of care based on current clinical guidelines outlined by your organization; additional testing of the mother and infant will be necessary. A standardized approach to managing expressed breast milk errors can provide comfort and reassurance to anxious parents.





1. Gartner LM, et al. Breastfeeding and the use of human milk. Pediatrics 2005;115(2):496-506. [Context Link]


2. Vohr BR, et al. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics 2006;118(1):e115-e123. [Context Link]


3. NSW Health. Safe management of breast milk. Safety advocate: a NSW Department of Health newsletter 2004 Jul. [Context Link]


4. Newell ML. HIV transmission through breastfeeding: a review of available evidence. 2008 Dec 12. [Context Link]


5. Pennsylvania Breastfeeding Coalition. Human milk guidelines for the nursery/NICU. Wilkes-Barre, PA; 2004. [Context Link]

Pennsylvania Patient Safety Authority's Resources


Visit the Patient Safety Authority's Web site ( for a toolkit on the mismanagement of breast milk that includes the following:


* handouts for patient and staff about infection risks associated with breast milk safety.


* a sample policy that can be adapted to be facility-specific.


* a stand-alone, plan-of-care algorithm for when breast milk mismanagement occurs.



Click on "Advisories and Related Resources" in the left-hand column of the Authority's home page. Then click on "Resources Associated with Patient Safety Advisory Articles" in the main text of the page. To view the toolkit, click on "Expressed Breast Milk Toolkit" in the main text of that page.