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Error kills 2 infants in Indiana



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Sep 17, 2006 07:51 PM

Error kills 2 infants in Indiana

Updated Sep 19, 2006 at 08:22 PM by brian

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.


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67 Comments
No. 1
from EricJRN
Old Sep 17, 2006, 08:00 PM

Default Re: Error kills 2 infants in Indiana
Sounds like a good example of a situation where system issues combine with human error. Very sad.
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No. 2
Old Sep 17, 2006, 09:23 PM

Default Re: Error kills 2 infants in Indiana
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
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No. 3
Old Sep 17, 2006, 09:35 PM

Default Wrong strength Heparin = 2 NICU deaths
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.
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No. 4
from Jolie
Old Sep 17, 2006, 09:46 PM

Default Re: Error kills 2 infants in Indiana
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.
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No. 5
from CHATSDALE
Old Sep 17, 2006, 09:54 PM

Default Re: Error kills 2 infants in Indiana
tragic
check twice act once

this pharmacy and the nurses are equally at fault there are a lot of similiar packaged meds no excuse
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No. 6
from sirI
Old Sep 17, 2006, 09:55 PM

Default Re: Error kills 2 infants in Indiana
Post #4 merged with existing thread.
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No. 7
from nuangel1
Old Sep 18, 2006, 12:42 AM

Default Re: Error kills 2 infants in Indiana
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.
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No. 8
from candicane
Old Sep 18, 2006, 08:27 AM

Default Human Error Blamed for 2 Preemie Deaths
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
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No. 9
from CrunchRN
Old Sep 18, 2006, 08:30 AM

Default Re: Human Error Blamed for 2 Preemie Deaths
What a tragedy. I am sure all those involved are absolutely beyond comfort.
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