Babies given wrong dose of Heparin @ Cedar Sinai

How ironic that a heparin flush is considered both "routine" and can cause such damage.

I don't mean to downplay the importance of checking medications, or the enormous responsibility we have to adminster them correctly, but heparin flush is not a dangerous drug. Heparin is, and should have never been stocked where it was.

About the disciplining of nurses, my sister - a nurse of 30 years said to me: you make a mistake? your fault. The md makes a mistake? your fault.
Is she being too cynical?
Diahni

Given that this is such a huge safety issue, one would think that at least one other person, other than the dispensing nurse, would have some oversight. Aren't nurses in the best position to make changes to improve safety?
Diahni

Mr. Quaid said something about nurses protecting hospitals, doctors protecting ... I didn't hear it all, but the word "protect" was used alot. If he thinks nurses are protecting hospitals, he might need to talk to more nurses.
Thank Heavens those children are alright.
He is apparently creating a foundation re medication errors. "Over 100,000 deaths a year". Where are these deaths? Many, many, years of nursing and I have never personally witnessed or even heard of a death by medication error other than in the news, and that doesn't add up to 100,000 people.

So, what is used now to flush a lock? Saline?

The news media recently reported that three premature infants died at a Midwestern hospital after receiving an overdose of heparin last weekend. Two, possibly three, other babies also were affected but are not in danger. Apparently, 1 mL heparin vials that contained 10,000 units/mL were placed incorrectly into a unit-based automated dispensing cabinet where 1 mL, 10 units/mL vials were normally kept. The vials looked very similar (see photo to the right). Several nurses requested 10 units/mL vials to prepare an umbilical line flush and were directed to that drawer, but did not notice that the vials contained the wrong concentration. No doubt there’s a lot more to the story but, for now, we have to say that similar medication errors could probably happen in most hospitals.

Automated dispensing cabinet filling errors are quite common. Please take a close look at your own restocking processes. Having a double-check of items before they leave the pharmacy is an important way to prevent mistakes, but even that is not fool-proof. Wherever possible, hospitals should avoid stocking items on nursing units that require further preparation by nurses before administration. As you examine your own practices, pay special attention to cabinets that are used for neonates and pediatric patients, since these are especially high-risk patients. For example, assess the medications and strengths that are stocked in cabinets.

The hospital involved is lowering the 10,000 unit strength of heparin. Perhaps this is time for you, too, to consider what might be removed for safety sake. Although not a factor in this case, this is also a good time to examine which medications are being removed from the cabinet without a pharmacist's review.

Also, even with the perceived safety of automated dispensing cabinets, hospitals should take steps to minimize look-alike packages and labels. Finally, if you aren’t already discussing bar coding at your location, it’s time to do so. FDA began requiring bar codes on drug containers for a reason—to help all of us prevent medication errors. Bar coding is valuable for bedside scanning to confirm the accuracy of the patient, drug and dose. But even without bedside scanning, cabinet vendors also provide bar code systems for assuring proper medications are stocked. We don't profess to know the easy answers, but this tragic case brings to light a serious national problem about which all should be concerned.

We start this year’s “high-alert medication” feature with anticoagulants—unfractionated heparin, low-molecular weight heparin, and warfarin. When used or omitted in error, anticoagulants can cause life-threatening or fatal bleeding or thrombosis. These drugs are among those that will be receiving targeted attention during the coming year from the Joint Commission, which has posted for comments a proposed 2008 National Patient Safety Goal associated with anticoagulation therapy (www.jointcommission.org/NR/rdonlyres/47F81056-2F85-494F-978A-7CB0 908D0DB4/0/08_potential_HAP_NPSG.pdf), and from the Institute for Healthcare Improvement (IHI), which has targeted anticoagulants and several other high-alert drugs for improvement in its recently launched 5 Million Lives Campaign (www.ihi.org/IHI/Programs/Campaign/). Common risks we have identified with these medications are provided in a bulleted list below, and our suggested safety improvements are presented in a checklist format that follows.

In addition to the risks and suggestions for improvement below, ISMP highly recommends conducting an interdisciplinary failure mode and effects analysis (FMEA) within your facility to identify organization-specific sources of failure with the use of anticoagulants, and to individualize the key improvements needed to reduce the risk of harmful errors with these medications. To assist you, ISMP has created a sample FMEA, which can be found at: www.ismp.org/Tools/FMEAofAnticoagulants.pdf. In the sample FMEA, the severity score for each failure mode has been included. Since the probability of each failure and its ability to be detected before causing patient harm will vary from organization to organization, the probability and detectability scores have been omitted so that each facility can make its own assessment of these vulnerabilities.

A deeper analysis of these heparin errors underscores two fundamental problems in today’s healthcare industry that continue to threaten patient safety:

• Our failure to fully adopt a learning culture
• Our failure to be truly mindful about safety.