Babies given wrong dose of Heparin @ Cedar Sinai - page 4

I'm a new nurse and haven't worked in a hospital setting yet, but I was under the impression a lot of facilities were getting away from heplocks and using saline locks instead??? ... Read More

  1. by   cardiacRN2006
    Quote from DutchgirlRN
    Besides what is a 10,000 unit bottle of Heparin doing in a neonatal area? Makes no sense, no sense what-so-ever. Pure stupidity.
    Because it was placed there accidentally by a pharmacy technician...
  2. by   DutchgirlRN
    Quote from cardiacRN2006
    Because it was placed there accidentally by a pharmacy technician...
    So the stupidity remains. The nurse obviously picked it up and administered it without looking at the label. And...this happened 4 times? Twice with each baby? Also with other patients? Nothing about the story seems straight.
    Last edit by DutchgirlRN on Nov 21, '07
  3. by   bullcityrn
    "Cedars-Sinai Medical Center, one of the United States' leading hospitals, apologized on Wednesday for what it called the "preventable error" that led to the twins and another unidentified child being given 10,000 units of the anti-coagulant Heparin, instead of the normal 10 units given to babies..."

    Full article here:

    http://omg.yahoo.com/dennis-quaid-tw...dose/news/4208
  4. by   sirI
    Post #42 merged with existing thread.
  5. by   SuesquatchRN
    Okay, I am missing something.

    A unit in insulin generally equals a ml. So how big would a freakin' syringe have to be to contain 10,000 u of hep?

    What am I missing?

    And who just grabs big, honkin' syringes and starts whacking teensy babies with 'em? I don't care where the aide alledgedly left 'em.
  6. by   cardiacRN2006
    Quote from Suesquatch
    Okay, I am missing something.

    A unit in insulin generally equals a ml. So how big would a freakin' syringe have to be to contain 10,000 u of hep?
    Well, the only time I have seen a unit of insulin equalling a mL is in an insulin gtt.

    In my unit, the 5000 unit vial of Heparin is in one mL. So in that case, 10,000 units would be 2 mL.
  7. by   SuesquatchRN
    Every place I've been 10u of insulin = 10 mL.

    Wow, 5,000 u in a mL? Now I understand how that could have happened.

    Wow.

    Thanks.
  8. by   cardiacRN2006
    Yep. I draw it up in a TB syringe.
  9. by   prmenrs
    Quote from suesquatch
    okay, i am missing something.

    a unit in insulin generally equals a ml. so how big would a freakin' syringe have to be to contain 10,000 u of hep?

    what am i missing?

    and who just grabs big, honkin' syringes and starts whacking teensy babies with 'em? i don't care where the aide alledgedly left 'em.

    they make different concentrations. you can have a 1 ml vial w/10u/ml or a 1 ml vial w/10,000u/ml. identical sized vials, identically shaped, colors (as i previously posted): blue and blue. you really have to look closely.

    we had a near miss w/this same situation in our unit. the tech stocked the pyxis w/the wrong stuff.

    but, my point is that the "root cause" is the packaging. the manufacturer should never have packaged them so similarly. the fact that they continue to do so is beyond belief. inexcusable. :angryfire :trout: and, of course, that is never mentioned in the press releases. frosts my cookies.
  10. by   elizabells
    Apparently Baxter flat-out refused to change the packaging after the Indianapolis incident. Shortly after that my hospital stopped using Baxter for a lot of our tubing and IV connectors. I don't know if it's connected, but I like to think it is.
  11. by   DutchgirlRN
    Quote from Suesquatch
    Every place I've been 10u of insulin = 10 mL.
    Wow, 5,000 u in a mL? Now I understand how that could have happened.
    Thanks.
    Recheck those syringes Sue...An insulin syringe holds 1 ml of insulin which is 100 units.

    Where I work 2 cc vials of Heparin equal 10,000 units.

    You cannot compare units of Insulin with units of Heparin because there is no comparison...like apples and oranges.
    Last edit by DutchgirlRN on Nov 21, '07
  12. by   prmenrs
    Quote from elizabells
    Apparently Baxter flat-out refused to change the packaging after the Indianapolis incident.
    Reprehensible!
  13. by   MrsWampthang
    Quote from DutchgirlRN
    Recheck those syringes Sue...An insulin syringe holds 1 ml of insulin which is 100 units.

    Where I work 2 cc vials of Heparin equal 10,000 units.

    You cannot compare units of Insulin with units of Heparin because there is no comparison...like apples and oranges.
    Yeah, I agree. I know I have only been a nurse for 6 years, but I've worked at 3 different hospitals and at all 3, 10 units of insulin is drawn up using a one ml insulin syringe which made it equal about 1/10th of an ml. I have never seen or heard of 10 units of insulin being give in a 10 ml syringe. Where I worked we had 5000 units of heparin in 1ml for subq injestion and 3ml syringes of heparin (can't remember the concentration of heparin) for flushes. The biggest problem I can see is that the color of the vials are so similar that it would be easy to mix them up, but still no excuse for this accident to happen again. I would have thought that after the Indy incident, EVERYONE from pharmacy to techs to nurses would be making extra sure that the heparin is the right concentration, especially in a NICU or a peds floor. Such a preventable tragedy. My prayers are with all the little patients that this happened to.

    Pam
    Last edit by MrsWampthang on Nov 22, '07

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