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DOI
https://doi.org/10.63853/UEFX4176
Description
QUALITY IMPROVEMENT
Background: Due to changes in Texas reimbursement, the Plano campus was transferring neonates, infants under 28 days of life, to the Dallas campus. It was decided in 2023 to obtain a neonatal designation for the Plano campus. A Program Manager was hired as part of the requirements and a quality and Patient Safety committee was formed. As part of the program, quality data collection was required. As a Level I designated facility, expressed breastmilk verification was one of the required data sets to be collected. It was discovered that staff at the Plano campus were not scanning expressed breast milk(EBM). Of the over 100 nurses who attended neonatal classes, only 3 said they had ever scanned EBM at the Plano campus. Each of these three described a different process and none of them were correct when looking at the policy on Breast Milk Administration. With this information, we realized we must improve our process.
Methodology: Due to changes in Texas reimbursement, the Plano campus was transferring neonates, infants under 28 days of life, to the Dallas campus. It was decided in 2023 to obtain a neonatal designation for the Plano campus. A Program Manager was hired as part of the requirements and a quality and Patient Safety committee was formed. As part of the program, quality data collection was required. As a Level I designated facility, expressed breastmilk verification was one of the required data sets to be collected. It was discovered that staff at the Plano campus were not scanning expressed breast milk(EBM). Of the over 100 nurses who attended neonatal classes, only 3 said they had ever scanned EBM at the Plano campus. Each of these three described a different process and none of them were correct when looking at the policy on Breast Milk Administration. With this information, we realized we must improve our process.
Outcomes:
- Verification rates increased from 20 % to over 90% hospital wide.
- Units had different rates, we will work on different strategies for following policy with each unit.
Publication Date
11-24-2025
Disciplines
Pediatric Nursing
Recommended Citation
Lathrop, Deb, "Importance of Expressed Breast Milk Verification and Patient Identification" (2025). 2025. 28.
https://scholarlycollection.childrens.com/nursing-anf2025/28
Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.
