Another heparin overdose...to a celebrity's children this time

[Christina R.N.]

http://www.foxnews.com/story/0,2933,312357,00.html
The newborn twins of Dennis Quaid were apparently given 10,000 u of heparin instead of 10u of heparin. Didn't this hospital have safeguards in place after the 2006 incident at a hospital in Indiana where preemies died from a Heparin OD??? I am not in acute care anymore. Did any of your facilities change practices after the 2006 incident?

[PWhite]

In the end, I think it comes down to the Professional involved to recognize the difference in the number of 000's present in the Rx.

[nuangel2]

i agree it is up to the practitioner to know the drug and give correct dose.

[Grandma]

How are the babies doing?It's been a hectic week,and I haven't seen the news in I don't know how long.

[PaulaJo]

What's up with this? Do NICU nurses no longer get training? This is basic Standards of Care with newborns.

[Christina R.N.]

The latest info I heard was that they were expected to recover fully. I certainly agree that the administering nurse has to bear responsibility. However, I think that anytime you have similar errors occuring you have to look at building in safeguards. I googled this story and came up with another nursing site that was discussing this story. One of the responders had personally had a near miss with this exact same situation. The wrong heparin was stocked in the pyxis. I also heard of one hospital changing the hep-lock solution to a pre-filled syringe while keeping the 10,000 units in vials. They did this in response to the incident in Indiana last year. Maybe this incident, with the celebrity spotlight, will be enough for other hospitals to take a closer look.

[PaulaJo]

Christina, let us hope.
Once again I am amazed that; when pharmacy puts the wrong the in the Pyxis, it is just a mistake, when the nurse gives it, it is a medication error. I have actually heard pharmacy laugh when they say, "oh, it was just a mistake".

[bryan]

Me too Paula - and who's to say the 'rushed' and 'overworked' pharmacist or asst could never made a mistake and put the wrong or dose drug INTO those syringes ----- I suppose we have to do *something* - but human error will always be with us!!

[Christina R.N.]

Me too Paula - and who's to say the 'rushed' and 'overworked' pharmacist or asst could never made a mistake and put the wrong or dose drug INTO those syringes ----- I suppose we have to do *something* - but human error will always be with us!!

BD makes a pre-filled syringe for hep-lock solution.

[JanRNICU]

Yes, humans will always make errors. We need to stop blaming individuals and look at systems. I am not implying that each of us should not be held accountable. I've been an RN for 31 years and I haven't met a nurse that did not feel very accountable. Many time for things out of our control. When an error is made there are so many intervening variables. I can only imagine how distraught the nurse is who give the heparin! Systems need to stop pointing fingers; taking punitive action; and fix the SYSTEM. No system will ever be 100% error free but I can say we have a very long way to go to improve what we have now. Every day for 23 years as I walked onto the ICU, I prayed that I would never make an error and hurt another human being. " By the grace of God we go" The more they put on our plates the higher the likelyhood that we will make mistkes. Each of us can only take good care of soooooooooo many people at one time. From personal experience I can say that the demand on point-of-care nurses has never been higher. The nursing shortage continues to expand which in turn will make things even more difficult. Until the blame and punitive action mentality changes humans will make more mistakes then expected.
Just my opinion on this issue.

[jcprn1]

I have to agree, the 'professional' is 100% responsible to check and recheck and recheck any and all med dosages!!! ESPECIALLY, since that horrible incident in the newborn nursery! What does it take to make nurses be careful where meds are concerned?

[Christina R.N.]

Just read that the Quaid's are suing Baxter, the drug company, because of the look-a-like vials. This should be interesting. They might have a case since Baxter was aware of the issue after the incident last year.