No matter how good the system is, of checks and rechecks and triple checks,
people who are overworked will always make mistakes (so will people who are
not overworked, none of us is 100% perfect).  At the time my milk was
mistakenly given to another woman's infant in Indiana, there was a freezer
in the NICU absolutely jam-packed full of milk from probably 10 or 12
different mothers.  And there were probably 20 babies in Peter's NICU, and
two other NICUs on the floor (one for preemies, and one for serious
problems).  The nurses did a pretty darn good job of getting the right milk,
in the right order, to the right baby (colostrum first, once the baby could
take milk by mouth, 2nd day milk next, 3rd day milk after that, etc.).

There will continue to be medication errors, blood transfusion errors, organ
donation errors, surgical errors (removing the body part from the wrong side
of the body), and mother's milk given to the wrong baby.  A better way to
cut down on the error rate would be to have more nurses, shorter shifts,
fewer babies for each nurse to care for, etc.  In the grand scheme of
things, I'd say that last source of infection I would worry about for my
child in the NICU was human milk, no matter who it was from.

Kathy Dettwyler

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