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Babies given wrong dose of Heparin @ Cedar Sinai



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No. 40
Old Nov 21, 2007, 03:18 PM
Updated Nov 21, 2007 at 03:20 PM by DutchgirlRN

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by cardiacRN2006 View Post
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.
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No. 41
from NC_OR_RN
Old Nov 21, 2007, 06:50 PM

Default Quaid Twins Receive Overdose
"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
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No. 42
from sirI
Old Nov 21, 2007, 06:53 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Post #42 merged with existing thread.
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No. 43
Old Nov 21, 2007, 07:24 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
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.
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No. 44
Old Nov 21, 2007, 07:27 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by Suesquatch View Post
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.
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No. 45
Old Nov 21, 2007, 07:29 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
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.
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No. 46
Old Nov 21, 2007, 07:30 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Yep. I draw it up in a TB syringe.
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No. 47
from prmenrs
Old Nov 21, 2007, 07:57 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by Suesquatch View Post
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. And, of course, that is never mentioned in the press releases. Frosts my cookies.
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No. 48
from elizabells
Old Nov 21, 2007, 08:09 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
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.
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No. 49
Old Nov 21, 2007, 08:09 PM
Updated Nov 21, 2007 at 08:15 PM by DutchgirlRN

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by Suesquatch View Post
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.
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