Error kills 2 infants in Indiana

  1. INDIANAPOLIS - Two premature infants died and a third was in critical condition after being given adult-size doses of medication, prompting hospital officials to review drug-handling procedures.Adult doses of the blood-thinner Heparin were somehow placed in a drug cabinet at the Newborn Intensive Care Unit of Methodist Hospital, said Sam Odle, chief executive of Methodist and Indiana University Hospitals. The hospital said human error was to blame.
    In all, six premature babies were given the adult doses.

    Two-day-old Emmery Miller and five-day-old D’myia Alexander Nelson, both girls, died Saturday night, Odle said. Three other infants were in stable condition Monday morning at Methodist, and another who was transferred to Riley Hospital for Children was in critical condition, hospital officials said.The two girls who died were both born at 25-26 weeks’ gestation, Odle said. A full-term pregnancy lasts 38 to 42 weeks.
    “These are very, very small babies,” Odle said. “We are confident that no other infants except for the six were affected.”
    Heparin is routinely used in premature infants to prevent blood clots that could clog intravenous drug tubes, but an overdose could cause severe internal bleeding, said Dr. James Lemons, a neonatologist at Riley.


    Full Story: http://www.msnbc.msn.com/id/14883323/


    This is sad. My thoughts are with the families of the babies and also the nurse.
    Last edit by brian on Sep 19, '06 : Reason: added breif article snips
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  2. 67 Comments

  3. by   EricJRN
    Sounds like a good example of a situation where system issues combine with human error. Very sad.
  4. by   MrsWampthang
    The error effected a total of 6 premies. I think this is too many for it to be merely human error. What happened to the five rights? This is what happens when we get too complacent about checking our drugs before giving them. We just take them out of the pocket it is supposed to be in, taking for granted that it is what it is supposed to be and never eyeball it ourselves to make sure. This is a wake up call for all of us!!! Always, always, when giving meds check your five rights!!! Make sure that the human error factor stops short of patient harm!!!! I'll be keeping the nurse/s that made those errors in my thoughts and prayers; they must truly feel sick at having made those errors.

    Pam
  5. by   matchstickxx
    http://www.indystar.com/apps/pbcs.dl...LOCAL/60917001

    Very scary...Another report says 6 infants received the wrong dose before the error was discovered.
  6. by   Jolie
    What a terrible, preventable tragedy!

    This is what happens when we fail to learn from history. Almost 20 years ago, a similar mix-up between heparin (1000u/cc) and hep-flush solution (10u/cc) came to light in the NICU setting. Most institutions responded by refusing to stock either in the NICU, relying on pre-made solutions from pharmacy. Makes me wonder why these medications were even available on this unit.


    Eric is absolutely right that systems errors combined with human error to created this unforgivable situation.
  7. by   CHATSDALE
    tragic
    check twice act once

    this pharmacy and the nurses are equally at fault there are a lot of similiar packaged meds no excuse
  8. by   sirI
    Post #4 merged with existing thread.
  9. by   nuangel1
    its very sad .yes its partially pharmacy fault for stocking wrong med dose but its the nurse who admin fault for not checking label carefull and catching the error 2 babies died 4 more received it thats not exceptable.
  10. by   candicane
    I was just reading this article and thought I would post it, it will be interesting to follow and see how it plays out

    http://news.yahoo.com/s/ap/20060918/...preemie_deaths
  11. by   CrunchRN
    What a tragedy. I am sure all those involved are absolutely beyond comfort.
  12. by   sirI
    Posts # 9 and 10 merged with existing thread.
  13. by   oneLoneNurse
    Having worked as a pharmacy analyst with computer systems in a large teaching hospital I thought of the processes this would involve. Initially, I thought this was more a pharm error than a nursing error . How did the wrong concentration get in the pediatric drawer ? I know there are no checks to this. The pharm tech brings the med up to the floor and puts it in the drawer. BUT, you would think it might be labeled ADULT DOSE ONLY (and maybe that will be the fix). At our hospital this would not happen because the pediatric pharmacy is separate from the Adult pharm. The bottom line is that we as nurses are TOTALLY responsible for anything that we give. We need to read whats on the label (the five rights) before we give the med.

    I can imagine being on a busy floor, typing the correct patient's name in on the PYXIS, hitting the right med, seeing the drawer open, then giving the medication. I might glance at the label to see the medication is correct, BUT might not look at the concentration. I might wrongly assume that since I choose the right patient I had the correct medication in my hand. I would be greviously wrong.

    My heart goes out to the family. No apologies of any kind can bring back those loved ones. Nursing can be an unforgiving profession.
    Last edit by oneLoneNurse on Sep 18, '06
  14. by   perfectbluebuildings
    I am wondering how SIX babies got this before it was caught. How tragic and how chilling. My heart goes out to those families. And to the nurses involved, from the med errors I've made that (by the grace of God) never had any serious consequences and how horrible it felt, cannot fathom what they will go through. It does sound like someone just pulled out what they had thought was correct dose of heparin and looked like the right thing and did not read it well enough, and "helped" by flushing several kids' IVs?

    What a horrible situation. Five rights, three checks, this is a wake up to how very important those are. It is true Lonenurse that nursing and medical jobs in general are unforgiving in many aspects... can't really EVER "let it slide"...

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