WTF?!? Fourteen Preemies Given Blood Thinner Overdose at Texas Hospital

http://www.foxnews.com/story/0,2933,378001,00.html

Fourteen Preemies Given Blood Thinner Overdose at Texas Hospital
Tuesday, July 08, 2008

CORPUS CHRISTI, Texas — Fourteen babies in the neonatal intensive care unit of Christus Spohn Hospital South were given overdoses of the pediatric version of the blood thinner Heparin, hospital officials said.

The error in the dosage of the medicine, used to flush intravenous lines to prevent blood clots from forming, was discovered Sunday night by hospital nurses who noticed abnormalities in lab tests, said Spohn CEO Bruce Holstein. They discontinued its use immediately and gave newborns who needed it different medications.

Officials said two babies have been released since the discovery was made and the others were being monitored carefully. Holstein told the Corpus Christi Caller-Times for a story in Tuesday's editions that the babies' reactions to the overdoses varied, and he did not know details about effects.

It was unclear how much over the recommended dose was given to the 14 patients in the neonatal intensive care unit. There is a standard dose for newborns, Holstein said, and the dosage depends on the number of intravenous lines and the number of times those lines are flushed.

Pharmacy operations were halted temporarily Monday. He said the error was believed to have happened in the pharmacy when the medicine was mixed.

Holstein said hospital staff would report the incident to the Joint Commission on Accreditation of Healthcare Organizations, an independent, nonprofit agency that accredits and certifies more than 15,000 hospitals in the U.S.

I am guessing it's the same drug that Dennis Quaid is sueing the hospital for, as his twins were overdosed as well. He is railing against the hospital for some reason.

I think it was warifin or heparin and the bottle was the same color in large dosage as it was in the smallish dosage.

I would think the maker should make larger labels. And the nurses should stay off the patients pain killers so they can read the labels better.

At one point a hospital had me on warfarin and heparin, and they darned near killed me, literally.

Heparin is a double edged sword. If you give just the right amount, you prevent blood clots, if you give too much, you can cause bleeding. If you don't give enough, the patient is at high risk for blood clots.

One of the problems seems to be that is comes on so many concentrations. I have seen it 1:10, 1:100, 1:1000; 1:10,000. If the pharmacy mixes the dose from a multi dose vial, labels it correctly, then gives it to the nurse to adminster, you should be OK. But, if the bottle had been mislabled at the factory, or the pharmacist looks at it wrong, but labels it correctly, it can still be given wrong.

As a RN, I would rather draw from the original bottle than rely on the eyes of others for my dosage. Then I have another RN check while checking the original bottle, and my dosage.

Sometimes our systems of checks and balences work, and sometimes it creates so many layers, mistakes are bound to happen.

There are many things that need to be standardized and are not, yet hospital administration focuses on things that don't matter, and miss the forest for the trees.

dimensiondancer said:

I am guessing it's the same drug that Dennis Quaid is sueing the hospital for, as his twins were overdosed as well. He is railing against the hospital for some reason.

I think it was warifin or heparin and the bottle was the same color in large dosage as it was in the smallish dosage.

I would think the maker should make larger labels. And the nurses should stay off the patients pain killers so they can read the labels better.

Click to expand...

yeah

I read this to my DH (RN) and he said that if the hospital was repackaging the meds, as stated in the article, it was the fault of the pharmacy, not the nurses.