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Babies given wrong dose of Heparin @ Cedar Sinai

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megananne7 specializes in Assisted Living, Med-Surg/CVA specialty.

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elizabells is a BSN, RN and specializes in NICU.

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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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RainDreamer has 13 years experience as a BSN, RN and specializes in NICU.

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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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BittyBabyGrower is a MSN, RN and specializes in NICU, PICU, educator.

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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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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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sirI has 30 years experience as a MSN, APRN, NP and specializes in Education, FP, LNC, Forensics, ED, OB.

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Threads merged.

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gwenith is a BSN, RN and specializes in ICU.

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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.

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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elizabells is a BSN, RN and specializes in NICU.

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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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labcat01 is a BSN, RN and specializes in ICU, CVICU.

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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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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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392 Posts; 6,968 Profile Views

"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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392 Posts; 6,968 Profile Views

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?

Even 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.

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392 Posts; 6,968 Profile Views

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.

Nicely said - on behalf of all NICU nurses I thank you.

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