Babies given wrong dose of Heparin @ Cedar Sinai - page 6
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
Dec 7, '07Quote from prmenrsi am with you on this one. there are far too many issues like this with labelling that the drug companies take no responsibility for. there are some ampoules that virtually need a manifying glass to read - and as for expiry dates - some are almost impossible to read!!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.
if this makes the companies become a little more thoughtful then it is a good thing.
Dec 7, '07Quote from dawnglovesWell, and especially ones you have to draw up yourself. My hospital takes the stance that the fewer meds nurses have to draw up/mix, the better. As we've seen here.We stopped using heparin flushes for PIVs years ago. I am surprised places still do it.
Dec 10, '07Just an FYI, according to Entertainment Weekly, Quaid and his wife are suing Baxter over the packaging. I just hope they get the company to change the stupid packaging!!!
Dec 11, '07Quote from elizabellsWell, and especially ones you have to draw up yourself. My hospital takes the stance that the fewer meds nurses have to draw up/mix, the better. As we've seen here.
The Baxter ones are prefilled syringes, no mixing or drawing up required. I've worked with them in PICu, but our NICU just uses saline unless it's a locked Broviac or something.
Dec 29, '07Quote from dawnglovesThe NICU uses heparin all the time - to keep central lines open and to maintain PIV's. The correct vial is labeled simular to the wrong dose, but we only stock the correct dose in our carts."Ordinarily" babies don't get heparin.I have never given heparin to a neonate. Sure, it's mixed in with central access fluids, but unless these were cardiac kids I can't imagine why they were getting heparin.
Dec 29, '07Quote from JolieEven babys born near term can have complications esp. twins; and even after the RDS, sepsis, or whatever is resolved there can be feeding issues. Often the bigger baby takes longer to get going on feeding esp. brst feeding.Siri,
Why were the babies in the hospital then? I assumed that they were preemies, but this picture shows apparently healthy babies who were definitely not in need of NICU care. What took both babies back to the hospital with a need for IV access?
Dec 29, '07Quote from cardiacRN2006Nicely said - on behalf of all NICU nurses I thank you.It's obvious that you have never been a nurse, so please refrain from the quick judgement.
It's easy to pull a med from the pyxis, where it's always been and administer it like you always do. Especially if the wrong med is in the wrong spot.
This is an error, yes. Horrible, yes. But I wouldn't call it EXTREME carelessness. I won't throw stones on an error that can easily be my own.
Dec 29, '07Quote from cardiacRN2006Yep. I draw it up in a TB syringe.
Adult based nurses don't have a clue about the NICU do they!
Dec 29, '07It's interesting... one of our NNPs told me the other night that as long as a central line is running above a KVO rate with heparinized fluids, flushes don't actually NEED to be heparinized. We use straight saline for our PIVs, but gosh, can it be a bear trying to get heparinized fluid to flush a central/arterial line. Pharmacy is supposed to send us a bag each day for art lines, but after the intital placement, they don't send anything for PICCs. For a while people were just drawing off whatever art flush bag they could find, even for another patient, until someone helpfully pointed out what a massive infection control problem that was. Unfortunately, our pharmacy doesn't consider heparinized fluids a priority, so they can be really hard to get when you need them to flush a cranky PICC line.
Dec 29, '07Quote from elizabellsDepends on the baby, if fluids are restricted you have to use hep. to keep a line open some of our line we run at .2 cc/hr. Without hep a line ussually needs to run about 3ccc/hr huge difference. . And I have seen bigger babys back-up the IV at slower rates (PIV's).It's interesting... one of our NNPs told me the other night that as long as a central line is running above a KVO rate with heparinized fluids, flushes don't actually NEED to be heparinized. We use straight saline for our PIVs, but gosh, can it be a bear trying to get heparinized fluid to flush a central/arterial line. Pharmacy is supposed to send us a bag each day for art lines, but after the intital placement, they don't send anything for PICCs. For a while people were just drawing off whatever art flush bag they could find, even for another patient, until someone helpfully pointed out what a massive infection control problem that was. Unfortunately, our pharmacy doesn't consider heparinized fluids a priority, so they can be really hard to get when you need them to flush a cranky PICC line.
Dec 29, '07Wow, we never run a central or an arterial line at anything lower than 1.2cc/hr. We'll restrict absolutely everything else first. Even PIVs are usually run over that, unless it's only for intralipids or something. If it's a drip it's piggybacked with NS or D5 to make 1.2cc/hr. I see your point, that's just not our policy.
Jan 22, '08Forgive me - I know this is an old issue - but it just appeared in my local paper and I searched for it here.
Seems to me the problem with similar labeling of heparin is as old as time - or at least has been a problem since I graduated nursing school. Why haven't the drug companies changed their labeling practices??
**Also, and I know it was said already, but when I was trained we had the 3 R-s of patient medication administration. Now I understand it is 5 R-s. I am so sad that this happened, especially since the person administering the drug is the one who is ultimately at fault. Thank God the babies are ok, this could have been disasterous.
I really think this has as much to do with nursing staffing/shortages as it does education and drug labeling.
Anyone heard anything further on this issue?
** I meant to add - in nursing school, and in every facility orientation I have ever attended, this potential packaging problem with heparin has been brought to attendees' attention. We were told, "the packaging on different doses of this medication is very similar and mistakes have been made. Use the utmost caution when administering!"Last edit by Liddle Noodnik on Jan 23, '08 : Reason: Another thought
Mar 15, '08dennis quaid speaks to `60 minutes' about the ordeal that nearly killed his twins (people-dennis-quaid)
they recall dog food that came from china last year,'' quaid says. ``but they don't recall medicine that kills people if you give it in the wrong dosage. ... we think it's wrong.'
report airs sunday, march 16, at 7 p.m. et/pt.
debra bello, a senior director at baxter, explains why the company didn’t recall the old vials still in hospital storage rooms, from which the quaid twins received their overdoses. "because the product was safe and effective, and the errors, as the hospital has acknowledged, were preventable and due to failures in their system," says bello, pointing out that ultimately, the person administering the drug should have read its label.