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A. Labor and Delivery

• 1) Umbilical cord clamps are now used in addition to the traditional identification bracelets. Identification bracelets, which have a clamp that can be tightened but not loosened, are now placed on both ankles of an infant instead of on one ankle and one wrist. The likelihood of an umbilical cord clamp becoming accidentally dislodged is remote; in the three months since the clamp has been put in use, none has done so.
• 2) Only staff with a purple badge are permitted to transport babies on the Labor and Delivery floor. Fathers and other visitors to the mother and baby are no longer permitted to do so.
• 3) Placentas that do not require examination are now stored on the Labor and Delivery floor and are disposed of after seven days.
• 4) On the Labor and Delivery floor, entry and exit have been restricted and monitored through the use of alarms and cameras.
• 5) Signs have been placed at the entrances in front of elevators informing visitors that they must obtain a visitor badge from the information desk prior to visiting inpatients.
• 6) Access to Labor and Delivery scrubs has been restricted, via locks on locker room doors.
• 7) Mother and infant ID bands are being stored in a more secure location and access to them is more restricted.
• 8) The Labor and Delivery Unit Assistant Desk area has been remodeled to increase visibility of people entering the unit.
• 9) A stringent re-banding policy has been initiated, to cover cases where bands fall off or are removed.
• 10) A policy has been initiated to assure that mothers and infants arriving through the Emergency Department are banded with matching numbered bands and umbilical clamp before they leave that area. 11) Nurses now document when ID bands and clamp are placed on the mother and infant in the delivery room, and on what extremities.
• 12) The discharge policy has been revised to clearly state that a staff member will assist the mother and infant from the Labor and Delivery floor to the lobby.
• 13) A column has been added to the nursing flow sheet to document the ID checks that are now required every time a mother and infant are separated and reunited.
• 14) A "Patient Responsibility" sheet has been created to teach mothers how they can help maintain a safe environment for their infants while in the hospital.

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  15) The computerized Discharge/Furlough order form has been changed: prompt requesting documentation of the mother's ID number, the infant's ID number and locations of bands are now automatic.
• 16) Daily chart audits are being conducted to evaluate compliance with the new policies and documentation expectations.