Babies given wrong dose of Heparin @ Cedar Sinai

*cardiacRN2006* · Nov 21, 2007, 12:06 AM

Re: Dennis Quaid's twins & other babies given wrong dose of Heparin @ Cedar Sinai

Originally Posted by CyndieRN2007

Yup, in Indianapolis.

http://allnurses.com/forums/f195/err...ana179704.html

Maybe it's me and my wacko computer (it sucks) but when I click on the thread it just takes me to the main forums...

CyndieRN2007 · Nov 21, 2007, 12:10 AM

Re: Dennis Quaid's twins & other babies given wrong dose of Heparin @ Cedar Sinai

Originally Posted by cardiacRN2006

Maybe it's me and my wacko computer (it sucks) but when I click on the thread it just takes me to the main forums...

I know, weird.....I re-pasted the link and it should work now.....

http://allnurses.com/forums/f195/err...na-179704.html

**EricJRN** · Nov 21, 2007, 12:22 AM

Re: Dennis Quaid's twins & other babies given wrong dose of Heparin @ Cedar Sinai

This is certainly a strange-sounding story, but whatever comes of it, maybe the celebrities involved will help call attention to a systems issue so that it can be addressed nationally. Let's hope that this turns out to be a near-miss, too.

The Betsy Lehman case at Dana Farber comes to mind... where the health reporter died of a Cytoxan OD but it focused national attention on the issues surrounding ambiguous physician orders.

**prmenrs** · Nov 21, 2007, 12:56 AM

Re: Dennis Quaid's twins & other babies given wrong dose of Heparin @ Cedar Sinai

Why should it take that (celebrity involvement) to solve a problem that has been previously documented to cause deaths?

A responsible manufacturer would have taken care of this issue waay long time ago. Every one wants to jump on the nurses; med errors are usually system problems, and should be investigated, addressed and solved in that fashion, not just blaming the last link in the chain, i.e., the nurse.

**NRSKarenRN** · Nov 21, 2007, 12:59 AM

Re: Dennis Quaid's twins & other babies given wrong dose of Heparin @ Cedar Sinai

Moved story to CE as no public release of names.

See press release stating error occurred:
Statement of Michael L. Langberg, MD Chief Medical Officer, Cedars-Sinai Medical Center (November 20, 2007)

**EricJRN** · Nov 21, 2007, 01:38 AM

Re: Dennis Quaid's twins & other babies given wrong dose of Heparin @ Cedar Sinai

Originally Posted by prmenrs

Why should it take that (celebrity involvement) to solve a problem that has been previously documented to cause deaths?

A responsible manufacturer would have taken care of this issue waay long time ago. Every one wants to jump on the nurses; med errors are usually system problems, and should be investigated, addressed and solved in that fashion, not just blaming the last link in the chain, i.e., the nurse.

I completely agree. It's very, very sad.

It's Alisa · Nov 21, 2007, 01:50 AM

10,000 Units?!

Ok, so I just read about Dennis Quaid's babies getting 10,000 units of Heparin EACH...and that 13 other babies may have gotten that big of a dose too. So I must ask, no matter how busy you are, no matter how tired you are, no matter how little bit of attention your paying to your meds...wouldn't you just stop and think for HALF A SECOND "wait a sec, does the order seriously call for 10,000 units of heparin for a BABY!" And if it happened once, fine...medical error...happens all the time...but to over 13 patients?! come on!

**EricJRN** · Nov 21, 2007, 01:59 AM

Re: Babies given wrong dose of Heparin @ Cedar Sinai

Alisa,

I merged your thread into the existing one on this topic. It doesn't appear to be a situation where an order for 10,000 units was given. It looks like the person preparing the meds thought they were using a 1,000 unit vial, but they were using a 10,000 unit vial. The packaging is almost identical... an error waiting to happen - and at least the second widely publicized NICU/heparin incident in the last few months.

**prmenrs** · Nov 21, 2007, 02:08 AM

Re: Babies given wrong dose of Heparin @ Cedar Sinai

Actually, the dose that is usually given is 1/2 ml from a 10 u/ml [1 ml] vial. Vials are the same size, shape, and as I previously stated very similar shades of blue.

november17 · Nov 21, 2007, 04:32 AM

Re: 10,000 Units?!

Originally Posted by It's Alisa

Ok, so I just read about Dennis Quaid's babies getting 10,000 units of Heparin EACH...and that 13 other babies may have gotten that big of a dose too. So I must ask, no matter how busy you are, no matter how tired you are, no matter how little bit of attention your paying to your meds...wouldn't you just stop and think for HALF A SECOND "wait a sec, does the order seriously call for 10,000 units of heparin for a BABY!" And if it happened once, fine...medical error...happens all the time...but to over 13 patients?! come on!

The order didn't say that. The order was probably for 10 units. Unfortunately, the wrong vials were "set out"

I don't really understand it. Was it a pharmacy tech that made the error and the nurses didn't pick up on it?

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Babies given wrong dose of Heparin @ Cedar Sinai

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