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Babies given wrong dose of Heparin @ Cedar Sinai



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No. 60
from elizabells
Old Dec 04, 2007, 10:57 PM

Default Re: Quaid twins and heparin, what dose does your unit use?
Prmenrs said in another thread on the topic that on her unit, the two dosages are both packaged with blue labels of very similar shades. I recall reading an article that said after the last heparin/NICU incident, Baxter refused to change the packaging. Shortly thereafter, my unit started to change the vendor of some of our IV tubing, which happened to be... Baxter. So I hope the company is feeling some hurt from their intransigence. I mean, really. It's a label color. Just fix it.

NB: I don't know if the reason my unit switched vendors is because of this, but I like to think so.
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No. 61
Old Dec 04, 2007, 11:45 PM

Default Re: Quaid twins and heparin, what dose does your unit use?
We never draw up heparin. All our flushes are just normal saline or half normal saline .... nothing else. All fluids that include heparin come up mixed from pharmacy.
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No. 62
Old Dec 05, 2007, 11:29 AM

Default Re: Quaid twins and heparin, what dose does your unit use?
We use prepackaged hep flush syringes that are 1u/ml. We only use hep to flush central lines or AL's, we don't use them on PIV's. For our lines, we use 0.5u/ml bags that pharmacy makes. We don't even keep hep vials on the unit anymore, no where in the hospital does.

I can see how it would be easy to mix up, when you are just clipping along, you grab the vial, eyeball it, blue cap, yup, a one with some zeros, yup. Sometimes we do have to remind ourselves to slow down, but these companies do need to make things a bit safer by labeling things very clearly and not having the same color tops on vials of same meds but with different concentrations.
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No. 63
from dawngloves
Old Dec 06, 2007, 09:46 PM

Default Re: Quaid twins and heparin, what dose does your unit use?
We stopped using heparin flushes for PIVs years ago. I am surprised places still do it.
Art lines and PICCs have continues infusions containing heparin. They are mixed by pharmacy.
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No. 64
from sirI
Old Dec 06, 2007, 09:52 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Threads merged.
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No. 65
from gwenith
Old Dec 07, 2007, 08:18 AM

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

If this makes the companies become a little more thoughtful then it is a good thing.
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No. 66
from elizabells
Old Dec 07, 2007, 08:31 AM

Default Re: Quaid twins and heparin, what dose does your unit use?
Originally Posted by dawngloves View Post
We stopped using heparin flushes for PIVs years ago. I am surprised places still do it.
Well, 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.
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No. 67
from labcat01
Old Dec 10, 2007, 08:29 PM

Default Re: Babies given wrong dose of Heparin @ Cedar Sinai
Just 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!!!
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No. 68
from fergus51
Old Dec 11, 2007, 10:32 AM

Default Re: Quaid twins and heparin, what dose does your unit use?
Originally Posted by elizabells View Post
Well, 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.
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No. 69
from kitty29
Old Dec 29, 2007, 04:17 AM

Default Re: Dennis Quaid's twins & other babies given wrong dose of Heparin @ Cedar Sinai
Originally Posted by dawngloves View Post
"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.
The 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.
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