17 Preemies given overdose of Heparin

From the brief article, it sounds as if this was due to a mistake in mixing heparinized saline in the pharmacy, rather than other recent cases of selecting the wrong dose vial from the Pyxis.

This is even more frightening to me as a NICU nurse, because we have no choice but to trust the information on the label printed by pharmacy. If the label reads, "heparinized saline 1 unit/ml", there is no way for the nurse to tell the difference.

I totally agree with the above poster. I was am in the process of transferring back from NICU to ER where we mixed all of our own drugs. It makes me nervous to give anything that I don't mix myself. Even antibiotics.

Yeah, sounds like pharmacy error here.... at least they gave credit to the nurses for picking up on it....I once had pharmacy send me a bag of 25,000u heparin with the proper label of 250u/500ml on it...the bag had the 25,000u printed on it in big red letters. I don't know how they missed it.

This is just another reason for NICU nurses to be even more careful.

CNN News has reported that Christus Spohn Hospital in Corpus Christi, Texas has confirmed the death of a seven day old baby in their neonatal intensive care unit yesterday morning .
The infant was one of seventeen infants that may have received overdoses of the controversial drug Heparin

Just wondering what your unit does as far as flushes. We can only flush with NS unless we have an order for a hep flush by an MD, and it has to be in a premade syringe that we order, or made specifically 1X for that particular infant by the pharmacy. It is really scary to me to think that we have to "trust" what is on each med label, that the pharmacy really put in there what it says they did. I feel for the nurses that unknowingly administered this medication.

Read full story below:
No word on the autopsy results as of yet.

http://www.caller.com/news/2008/jul/...edicine-error/
http://www.kristv.com/Global/story.asp?S=8650791
http://corpuschristi.injuryboard.com...oogleid=243462

At least 17 infants received too much blood thinner while being treated in the neonatal intensive care unit at Christus Spohn Hospital South in Corpus Christi, Texas, according to news reports.

The Caller-Times says the babies received "as much as 100 times the recommended dosage of the blood thinner heparin." The Associated Press says an autopsy is scheduled for a newborn who died after workers administered the drug.

http://blogs.usatoday.com/ondeadline...ies-given.html

Is this the same incident?

http://allnurses.com/forums/f195/14-...in-315896.html

Yes, it seems to be the same incident.

It is tragic that a baby has died and I sincerely hope that the autopsy will shed light on the cause of death, whether it was related to the heparin overdose or not. Many prayers to the family of the infant and his caregivers.

Perhaps I'm just in a contrary mood today, but the following parts of the first article listed in discobunni's post are driving me nuts. Why do hospital spokespeople comment on things they obviously know nothing about, and why don't so-called journalists check their facts before printing inaccuracies?

"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."

So were the babies given a "standard dose" or were their doses individualized based on the "number of IV lines and the number of times those lines were flushed? Can't have it both ways.

"Flushing IVs to prevent blood clots is standard practice in hospitals, with most patients getting them flushed with saline. Saline, because of its higher sodium content, has an adverse affect on babies in the neonatal intensive care units and so it is common practice to use Heparin, which is a short-acting drug, Holstein explained."

Really? Heparinized saline has a lower sodium content than plain saline? Who knew?

Threads merged.

Pretty scary. I believe I just heard the second twin died as well.