As a result of an incident I personally experienced, a survey was carried out and of the 5 replies, 4 agreed on the following procedure for the tagging of neonates at delivery in OT (usually, post Caesarean sections).
Ms. Chin, the Labour Ward Manager was duly informed of our recommendations.
Dr. Ngun Kok Wah,
Secretary,
Medical Advisory Board,
Subang Jaya Medical Centre.
24 December 1999.
Ms. Chin Fong Lye,
Unit Manager,
Labour Ward,
Subang Jaya Medical Centre.
Dear Ms. Chin,
After consultation with the other
consultant anaesthetists, we are of the opinion that the current procedure for
the tagging of neonates delivered in the operating theatres is inadequate and
could lead to errors.
There have been instances where
the name on the nametag of the neonate did not correspond with the mother's
name. If the error had gone unnoticed, it would most certainly have been cause
for legal proceedings to be instituted against the hospital and its staff.
We would, therefore, like to
propose the following procedure for the tagging of neonates delivered in
operating theatres.
1.
The
neonatal/maternal nametags, which come in sets of threes with the same serial
number, should be filled in by the attending midwife before delivery.
2.
The
nametags should not be separated before delivery.
3.
After
delivery, before the neonate is taken out of the OT, the nametags should be
separated and immediately applied to the mother and the neonate respectively.
4.
The
name and serial number on all three tags must be counterchecked against one
another to ensure consistency and accuracy. As your practice is to place the
nametag on the mother's right wrist, we will help to facilitate this by
placing the mother's right arm on an arm-board.
Any suggestions you may have to
further improve the above proposal are most welcome. Feel free to contact me
at any time if you need any clarification.
Please reply soon so that the
proposal may be brought up at the relevant subcommittee for approval at the
next meeting.
Yours truly,
Dr. Ngun Kok Wah.
Secretary,
Medical Advisory Board,
Subang Jaya Medical Centre.
Concerning the tagging of neonates in OT, Ms. Irene Quah informed me that the mother had to be tagged in the ward before coming to OT. Hence, our proposal had to be modified. The suggestion is that while the mother will be tagged in the ward, the midwife will have to countercheck the tags with the one on the mother in OT before tagging the neonates in the OT. To facilitate this, I hope you will all cooperate by putting the right arm out on an arm-board.