Babies given wrong dose of Heparin @ Cedar Sinai - page 9

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   la bellota
    self disclaimer: I was a student nurse in '89. had to give it up. And now will graduate in 30 days (woot)

    Ok so ....back the first time I went to nursing school....there used to be a med nurse. I wonder why they don't go back to that. Someone whose sole job for that shift was giving meds.

    Do you all know why that changed and if you think it would be good to do again?
  2. by   Diahni
    Quote from la bellota
    self disclaimer: I was a student nurse in '89. had to give it up. And now will graduate in 30 days (woot)

    Ok so ....back the first time I went to nursing school....there used to be a med nurse. I wonder why they don't go back to that. Someone whose sole job for that shift was giving meds.

    Do you all know why that changed and if you think it would be good to do again?
    Given that this is such a huge safety issue, one would think that at least one other person, other than the dispensing nurse, would have some oversight. Aren't nurses in the best position to make changes to improve safety?
    Diahni
  3. by   bollweevil
    Quote from Freedom42
    This will be featured tonight on "60 Minutes." The details have been posted in lengthy threads on this forum. I'm not aware of the moderators editing or deleting any of those posts.

    As I recall, staffing was not the issue when the Quaid children were overdosed. The hospital still had heparin on its shelves that bore old labels. A nurse did not check the label and overdosed the children.

    The Quaids are going after the drug company because they have no cause of action against the hospital or the nurse. That's because the children were given the antidote and recovered. Had they been damaged, the family would have a claim. I don't doubt that their lawyer gave another reason when speaking to a reporter about not going after the nurse, though. To say "we don't have a claim" diminishes the public view of their case.

    It seems like if a nurse gave the wrong dose, there is a cause of action against that nurse, doesn't it? Not that it would have been solely the nurse's error, as the bottle should have been totally distinctively labeled and the pharmacy director should have been part of that labeling effort and Nursing directors should have had a hand in getting it properly labeled. But the nurse who actually made the error, unfortunately, is also liable. Right?

    Are the twins alright?
  4. by   Diahni
    Quote from bollweevil
    It seems like if a nurse gave the wrong dose, there is a cause of action against that nurse, doesn't it? Not that it would have been solely the nurse's error, as the bottle should have been totally distinctively labeled and the pharmacy director should have been part of that labeling effort and Nursing directors should have had a hand in getting it properly labeled. But the nurse who actually made the error, unfortunately, is also liable. Right?

    Are the twins alright?
    I think they are - two issues - were there damages? There weren't, though the parents might think a period of extreme worry are indeed damages. Secondly, to be sure, the nurse lost her license, though I don't know for sure. When you sue somebody, you have to prove damages, which is hard to do, even in car accidents. Nothing like this kind of case that reminds me of the grave responsibility of dispensing a serious medication. Somebody else mentioned there should be double checks on med dispensing. Here's a parallel - writers know it's wise to have somebody else check and edit their work. It's hard to see our errors when we're the ones that made them in the first place. Making a typo vis a vis a med error is no comparison! A good question is this: If there are pushing two hundred thousand FATAL errors (got this stat from the net,) shouldn't there be more than one person checking on the five "rights"??? Nobody wants to die, or have a loved one die from an unnecessary error, and nobody wants to cause one. Same old same old: where is administration on this?
  5. by   Jolie
    Dahni,

    A few points in your post jump out at me. First of all, simply because the babies did not suffer permanent injury that we know of, (They are infants, with many years of growth and development ahead of them during which deficits may become apparent.) does not mean that there are no damages. They spent more time in NICU than was otherwise necessary, were separated from their parents, were exposed to painful treatment, and their parents undoubtedly experienced extreme mental anguish over the possibility of losing their previously relatively healthy infants.

    Secondly, unless it can be demonstrated that the nurse acted recklessly or intentionally, s/he may not (and probably should not) lose her license over this incident. The problem of mis-identifying heparin strengths is an issue that was well-known to the manufacturer, (who refused to address it following a similar incident in Indianapolis in which 3 babies died) and should have been well-known to any hospital with a NICU. Administration of a drug ultimately rests with the nurse caring for the baby, a huge responsibility. But not every error in medication administration is solely the fault of the nurse. There are systems errors that allowed the manufacturer to continue to supply medication in packaging that was likely to be confused, technicians (who are not pharmacists) who stock medication and are more likely to make a mistake in stocking than a pharmacist, unit-based policies and procedures (established by management) that do not require cross-checking of medications like heparin flush, which are regarded to be "routine" meds, and staffing issues (determined by administration) that may put time pressure on nurses caring for too many babies.

    To insist that only the nurse administering the medication be disciplined is short-sighted, ineffective and does nothing to prevent future errors.

    As for medication nurses - they are sometimes utilized in team-nursing settings, a care-delivery system that is not at all appropriate for a NICU, or any intensive-care setting.
    Last edit by Jolie on Mar 17, '08
  6. by   Diahni
    Quote from Jolie
    Dahni,

    A few points in your post jump out at me. First of all, simply because the babies did not suffer permanent injury that we know of, (They are infants, with many years of growth and development ahead of them during which deficits may become apparent.) does not mean that there are no damages. They spent more time in NICU than was otherwise necessary, were separated from their parents, were exposed to painful treatment, and their parents undoubtedly experienced extreme mental anguish over the possibility of losing their previously relatively healthy infants.


    Jolie: You're right - who knows what the long term will bring? As well, you never know the source of the problem - some people are convinced that vaccinations cause autism in their kids - they may or may not be right, but either way, it can be so hard to prove.

    J:Secondly, unless it can be demonstrated that the nurse acted recklessly or intentionally, s/he may not (and probably should not) lose her license over this incident.

    D: Good to know - I was taken aback when I saw on a nursing license list that many people lost licenses for "charting errors" -could this be? Yes, it's a huge responsibility, but to err is human, as well.


    The problem of mis-identifying heparin strengths is an issue that was well-known to the manufacturer, (who refused to address it following a similar incident in Indianapolis in which 3 babies died) and should have been well-known to any hospital with a NICU. Administration of a drug ultimately rests with the nurse caring for the baby, a huge responsibility. But not every error in medication administration is solely the fault of the nurse. There are systems errors that allowed the manufacturer to continue to supply medication in packaging that was likely to be confused, technicians (who are not pharmacists) who stock medication and are more likely to make a mistake in stocking than a pharmacist, unit-based policies and procedures that do not require cross-checking of medications like heparin flush, which are regarded to be "routine" meds, and staffing issues that may put time pressure on nurses caring for too many babies.

    To insist that only the nurse administering the medication be disciplined is short-sighted and ineffective.

    As for medication nurses - they are sometimes utilized in team-nursing settings, a care-delivery system that is not at all appropriate for a NICU, or any intensive-care setting.
    D: Nothing like being overly cautious. How ironic that a heparin flush is considered both "routine" and can cause such damage.

    Though celebrities may expect special treatment no matter where they go, these kind of mistakes can affect anybody.

    About the disciplining of nurses, my sister - a nurse of 30 years said to me: you make a mistake? your fault. The md makes a mistake? your fault.
    Is she being too cynical?
    Diahni
  7. by   Jolie
    Quote from diahni
    how ironic that a heparin flush is considered both "routine" and can cause such damage.

    i don't mean to downplay the importance of checking medications, or the enormous responsibility we have to adminster them correctly, but heparin flush is not a dangerous drug. heparin is, and should have never been stocked where it was.

    about the disciplining of nurses, my sister - a nurse of 30 years said to me: you make a mistake? your fault. the md makes a mistake? your fault.
    is she being too cynical?
    diahni
    no, she is not too cynical. she is a realist. it is a fairly recent movement to understand that medication errors are not necessarily the sole responsibility of the person who administered the drug. anyone with 30 years of nursing experience well remembers the day when punitive measures were the norm, not the exception. in many places, they may still be.
  8. by   mscsrjhm
    Quote from Diahni
    Given that this is such a huge safety issue, one would think that at least one other person, other than the dispensing nurse, would have some oversight. Aren't nurses in the best position to make changes to improve safety?
    Diahni
    Gotta love that last sentence.
  9. by   BrokenRNheart
    Quote from Mschrisco
    Mr. Quaid said something about nurses protecting hospitals, doctors protecting ... I didn't hear it all, but the word "protect" was used alot. If he thinks nurses are protecting hospitals, he might need to talk to more nurses.
    Thank Heavens those children are alright.
    He is apparently creating a foundation re medication errors. "Over 100,000 deaths a year". Where are these deaths? Many, many, years of nursing and I have never personally witnessed or even heard of a death by medication error other than in the news, and that doesn't add up to 100,000 people.
    Nurses are protecting themselves which appears to be protecting the hospital. You pray they will be on your side so you do what you have to. I did hear that. I didn't realize it was Dennis. That was in the beginning and I was cooking dinner and didn't catch it all.

    I have heard of a small number of deaths. It depends on where and who you are at the time. They keep it very hush hush. When I was in charge on an oncology unit, there was an immediate and emergent admission issue that involved a patient that went home on a chemo pump. Turns out it was a nurse in training that set the pump and somehow the double check didn't double check it. There was a lot of hype about that admission that night but that was immediately quieted down by administration and not heard of again except for hearing that patient went to dialysis and didn't make it. Know nothing more.

    I also met a lady that claimed she won the largest lawsuit against another local hospital for overdosing her on cytoxan and causing heart failure at a very young age. Wasn't much media on that one either. The only reason I knew is because she was a patient.

    Those incidents are kept quiet.
  10. by   sunnysideup09
    Indianapolis had the same issue where babies were given a heparin overdose and did die. Unfortunately it is a system error and not the drug maker's error. There are so many places where this could have been prevented starting with training overall. There should have been double check in pharmacy prior to the med being stocked, and lastly, the nurse should have checked the vial. What hapened to the rights of medication administration?

    This isn't the first time the drug maker has been asked to switch the label colors, but my thought also is why is heparin being used in NICUs anyway? So many NICUs are going away from using heparin.
  11. by   shamus
    Why was Heparin in the baby unit?
  12. by   chowlover
    So, what is used now to flush a lock? Saline?
  13. by   dawngloves
    Quote from chowlover
    So, what is used now to flush a lock? Saline?
    We did away with heparin flushes years ago in my unit. Even before the accident in Indiana. We would flush a PIV once a shift and were heparinizing our babies. We now use NSS.
    Central lines are flushed with heparinzed NSS sent pre mixed by pharmacy.

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