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A. Departmental Improvements

• 1) Labor and Delivery Unit Procedures: There is an extra adult identification wrist band in the packages with the new umbilical clamp, besides the wristband intended for use by the mother. Since the Medical Center has stopped allowing fathers and other visitors to transport babies within Labor and Delivery, this second adult wristband is not needed. The procedures in place when the committee did its investigation called for the attending nurse to dispose of this extra wristband, but there was no procedure for documenting the disposal. If the wristband is not properly disposed of, it could be used by an unauthorized individual to procure a baby from the nursery or to have access to a baby without the mother's knowledge. Recommendation: The Medical Center should purchase packages with only one adult wristband. The committee believes this would decrease the possibility of unauthorized persons having access to an infant. Until the new packages of wristbands are obtained, disposal of the second adult wristband must be documented in the patient's medical record.
• 2) Morgue Administration: When the committee reviewed the procedures for releasing remains ftom the Morgue, it discovered that no one person or department was charged with responsibility for release. Bodies were being given to funeral homes and families by transport workers, rather than by an individual specifically designated and trained for this task.
• Recommendation: The committee recommends that all releases of remains from the Morgue be performed by a designated person or persons. The ideal situation would be to centralize Autopsy and the Morgue in one room so that transfers from area to area would be minimized. Also, we would recommend that one person be responsible for this area and for ensuring that the inventory of bodies, organs, and products of conception is accurate and complete. This person would also be responsible for releasing remains under routine circumstances.

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  Additionally, an individual or individuals should be charged with ensuring that fetal remains that might be claimed by the family make it safely from Labor and Delivery to the Morgue. Designating specific persons to be responsible for these tasks should improve consistency in their performance. During each move between departments, accountability must be ensured by means of a "check-in" and "check-out" system within each department.
• We also recommend that when remains are released to a family (a rare occurrence), they be offered the help of a chaplain or bereavement counselor, which the family could accept or decline. With few exceptions, all releases of remains should be done during designated business hours, and a designated administrator should personally handle both after-hours releases and unusual cases, including release of remains to families. All persons handling fetal remains, including products of conception, should receive sensitivity training so that proper consideration is given to the handling of these remains and to the families involved.