A pediatric intensive care facility was experiencing errors where the mothers expressed milk was provided to the wrong baby.   

The intensive care environment separates the normal mother and baby interaction, where the mothers are at home, whilst the baby is in hospital. Mothers express milk, this is collected and delivered to the care unit. The milk is matched to the baby using two-factor authentication.

The hospital deployed a six sigma lean thinking team to solve the problem. The result was more process and no change in the errors.

The hospital established an Art of Work Resilimap Learning Team, that harnessed the frontline workers as the experts. The learning team developed a new method for patient identification that applied human factor principles that removed the baby matching error.

The solution has broad applications across healthcare where identification errors are a significant patient safety problem.