On February 27, 1989, Ms. Zhang gave birth to her son Wang Ye (a pseudonym) by cesarean section at Shanghai No. 1 Maternal and Child Health Hospital. For years thereafter, the son was said to not look like his parents. The husband, Mr. Wang, suspected his wife of cheating on him, and in 2004, they divorced. in 2011, Wang Ye’s father dragged the mother and son for a paternity test, which showed that neither Wang Ye was related to his parents. on the morning of July 29, the hospital involved had set up a special task force to assist the court in investigating the incident. Before the 1990s, the management of mothers and babies is not so standardized, there is no sound newborn identification system, birth registration is not standardized, the birth certificate can be arbitrarily altered, then the implementation of the system of separation of mothers and babies, after the delivery of the baby in the newborn room unified feeding for three days, the newborn baby held the wrong incident occurred repeatedly. However, this kind of thing, in a zero after the birth of children, has been difficult to happen. Reason one: mother and baby in the same room China began to promote mother and baby in the same room in the 1990s, and in the late 1990s, the full implementation. From the original form of care in which mothers and infants were separated, newborns were managed centrally and hand-fed, it was changed to a form of mother-infant room. In other words, unless a premature baby or a newborn is sick and needs to be admitted to NIUC for observation and treatment, mother and child live together throughout the hospital stay after delivery, and medical and other operations are separated for no more than one hour per day. Such a management model not only helps breastfeeding, but also enhances mother-child bonding, while the 24-hour postpartum non-separation model makes holding the wrong newborn a difficult task. Reason 2: Newborn wristbands In recent years, the wristband identification system has been implemented after the birth of a newborn, with a wristband with birth information tied to one side of each newborn’s wrist and ankle, and a breast plate with identification tied to the newborn’s clothes or package, with the name of the pregnant mother, the sex of the newborn, the date of birth, birth weight and other information written in detail on the wristband and breast plate, multiple links to avoid holding the wrong newborn. These wristbands and badges are required to be worn throughout the hospital stay, and the wristbands are designed in such a way that they cannot be removed at will, and must be cut off in the presence of the parents upon discharge. Reason 3: Newborn footprint collection As soon as the newborn is born, the footprint of the newborn’s right foot and the thumbprint of the mother’s right hand are collected and left on the newborn’s birth record. This record sheet with the newborn’s footprint and the mother’s handprint will be filed in the hospital along with the medical history and will be the first record of the newborn’s identity. Reason 4: Strict handover system On September 3, 2013, the General Office of the National Health and Family Planning Commission issued “Ten Provisions for Strengthening the Safe Management of Obstetrics”, which states in Article 6 that medical institutions shall establish a system and process for the identification and handover of newborns. The handover of newborns must be signed and confirmed by the medical staff and family members of both sides of the handover. Newborns need to leave the original ward for examination and treatment, must be accompanied by family members. Medical institutions should strengthen the capacity of obstetrics, neonatology and other key areas of security prevention, and establish strict 24-hour monitoring and management. With the implementation of this regulation, the supervision of newborns becomes particularly strict. Whenever a newborn leaves or enters a ward, the nursing staff in charge of the handover on both sides must verify the badge, wristband and gender of the newborn, even if the parents of the newborn have been in its presence. The 24-hour monitoring at the Mother-Baby Hospital makes it impossible to hold a newborn incorrectly. Nowadays, with such a strict and sound management model for newborns, incidents like the one told at the beginning of this article about the suspected wrong baby held 28 years ago can hardly happen again. However, we still need to pay attention to the “cheese principle” in safety management, to avoid multiple shortcomings at the same time, thus causing irreversible events.