Drug maker's warning after baby deaths: Read labels

NurseyBaby'05, BSN, RN · Feb 12, 2007

Especially for such a dangerous drug. It was Heparin! It's not like the patient got an extra colace. (I realize in a baby the extra loose stool would have a greater impact than an adult, but you get the point I'm trying to make.) As for them being stocked incorrectly, we have similar problems with our pharmacy with Potassium of all things! One of the things that makes it easier to catch is that they leave the outer plastic packaging and the central liine use only stickers on the 20 mEq bags. The 20 mEq bags are also smaller. Yes, the nurse and pharmacy should have double checked, but the impression I got from Baxter's statement was that they weren't willing to make small changes (like making the label pink) to prevent this happening in the future. :trout: Big thumbs down to them!

NurseyBaby'05, BSN, RN · Feb 12, 2007

This may be a solution. Stop using Baxter's product all together. I'm sure they would suddenly come up with a solution to this labelling problem if the potential for lost revenue reared it's ugly head. :rolleyes:

Since the mistake, Clarian has stopped stocking one of the Baxter heparin products and switched to one bottled by a different company, Odle said.

http://www.indystar.com/apps/pbcs.dll/article?AID=/20070210/LOCAL/702100479/1196

prmenrs, RN · Feb 12, 2007

We just had a "near miss" w/ this same product!!!!

Baxter needs to change the packaging. Period.

NurseyBaby'05, BSN, RN · Feb 12, 2007

:yeahthat: :yeahthat: :yeahthat: :yeahthat:

Thank you!

matchstickxx · Feb 14, 2007

We just had a "near miss" w/ this same product!!!!
Baxter needs to change the packaging. Period.

I know in the article Baxter states they haven't heard of any problems prior to the Methodist/Clarian incident. I just wonder how many "near misses" have actually occurred due to the similar labels.

prmenrs, RN · Feb 14, 2007

Not sure if everyone knows this, but "near misses" are required to be reported to the FDA.

Baxter may not have "known there was a problem" before that incident, but once was certainly enough to warrant a major change!!!

matchstickxx · Feb 14, 2007

Not sure if everyone knows this, but "near misses" are required to be reported to the FDA.
Baxter may not have "known there was a problem" before that incident, but once was certainly enough to warrant a major change!!!

I know this, but how many nurses who have actually experienced a near miss are too busy to write the incident report at the time and then, next thing they know, it is the end of the shift and they have forgotten about it?

Sadly, I have heard nurses I work with complain about a near-miss event but when I ask if they wrote it up, they usually say that they didn't have time.

At my old job I was on a medication safety committee. I know first hand that the hospital can't do anything about a problem if they do not know the problem even exists. We even simplified the reporting paperwork so that the nurse could either check a couple of boxes or, if there wasn't an applicable box to check, the nurse could write a quick message on the back of the page. Then imprint the form with the pt's addressograph and put the form into the pharmacy box. When we simplified the process to report, we started seeing more near misses reported.

At my current job, the reporting process is computerized and it takes an average of 10 minutes to access the correct report and fill in the report. I do not understand why it is the burden of the nurse (reporter) to fill in the patient's address and occupation at the time the report is completed. This sort of non-relevant info takes too much time to look up and fill in and discourages people from taking the time needed to report a near miss.