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Babies given wrong dose of Heparin @ Cedar Sinai



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No. 50
from prmenrs
Old Nov 21, 2007, 08:11 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by elizabells View Post
Apparently Baxter flat-out refused to change the packaging after the Indianapolis incident.
Reprehensible!
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No. 51
Old Nov 22, 2007, 11:53 AM
Updated Nov 22, 2007 at 12:06 PM by MrsWampthang

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by DutchgirlRN View Post
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
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No. 52
Old Nov 22, 2007, 12:04 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.
Now I'm missing something. I gave 1 unit of insulin subq injections all the time, which was like 0.01 of a 1ml insulin syringe, 10 units was 1/10 of an ml and given subq. Where do you work that you would give 10 units of insulin in a 10 ml syringe and how did you give it?

Pam
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No. 53
Old Nov 22, 2007, 12:10 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by DutchgirlRN View Post
Recheck those syringes Sue...An insulin syringe holds 1 ml of insulin which is 100 units.
Yeah, I know that. I always screw it up when I say it. Thanks, though.

The apples and oranges thing - yeah, bad comparison, I know. But I needed a frame of reference I could wrap my head around and this worked. I've never given a heparin injection, just Lovenox, and that comes pre-filled and ready to go.

Thanks.

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No. 54
from labcat01
Old Nov 24, 2007, 01:39 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by prmenrs View Post
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.
I hear what you are saying and I completely agree! I'm sure the manufacturers feel that changing the packaging would be seen as an admission of guilt. I wish there was more public outcry about this
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No. 55
from caliotter3
Old Nov 24, 2007, 03:46 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
The company could always wait until in-between mishaps and change the packaging with no public announcements. It's their problem that the packages are this way, they can fix it whenever they choose and state that they intended to do so anyway if they say anything at all. They choose not to do so. Thick-headed wrong thinking. Any facility that stops doing business with Baxter is making the right move IMHO.
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No. 56
from Kimbalou
Old Dec 04, 2007, 08:31 PM

Default Quaid twins and heparin, what dose does your unit use?
Not sure if there was a thread started about this yet. Recently, Dennis Quaid had twins. They went to the hospital for a staff infection and were given the 10,000 unit heparin/cc to flush their lines instead of the 10 unit heparin/cc. Now the Quaids are suing the drug company because the 2 vials look so similar.
Do you use the 10 unit/cc heparin in your unit? We don't. I'm glad. We use a pre-mixed bag made by pharmacy that comes 1/2u heparin/cc in normal saline. I've heard that the 10 unit/cc isn't really necessary, especially in low birth-weight premies. We used to use 10 units/cc at my other job, but only if the baby was over a certain weight.
Just curious if you have to deal with different heparin vials, I find this very scary. I hope the drug company changes their packaging and more hospitals just stop using it...and use a smaller dose like we do.
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No. 57
from elizabells
Old Dec 04, 2007, 08:48 PM

Default Re: Quaid twins and heparin, what dose does your unit use?
We use saline to flush PIVs. For our PICCs and Alines, we use 1:1 heparin premixed by pharmacy. The ONLY time I have ever drawn heparin from a vial was to anticoagulate a baby during the ECMO cannulation process. For the heparin drip on the ECMO pump, they use something like 60U/cc? It comes in a syringe, again mixed by pharmacy.
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No. 58
from Lindz
Old Dec 04, 2007, 10:03 PM

Default Re: Quaid twins and heparin, what dose does your unit use?
I don't work NICU, but peds med/surg. Our omnicell is stocked with prefilled 10 unit and 100 unit (for ports) heparin. The 10's are bright blue and the 100's are bright yellow and they are stocked on different shelves of the omnicell. You'd have to be blind to mix the two up.
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No. 59
from Kimbalou
Old Dec 04, 2007, 10:34 PM

Default Re: Quaid twins and heparin, what dose does your unit use?
Quaid is claiming that the 10 unit and 10,000unit are both packaged in the same way and both have a blue label...that's why he's suing.
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