Medication error causes 2 deaths in Indiana NICU

lovemyjob · Sep 21, 2006

We have 10units/1ml vials on our unit that we use for heplocking PIV's. If pharmacy stocked 10,000u/ml that could be a problem.

I thought heplocking pivs was a thing of the past. I have only heplocked a piv when I worked in a nursery and the lines kept ctotting between abx doses and the cjild was a very difficult stick. We only use 1/4ns for flushing piv's and we flush every 4 unless there are fluids running. When when I was in nursing school our instructors said they were nolonger flushing with hep because it wwas unnecessary, ns would do. The article made it sounds like using heparin was a stadnard (because it was used on several others)....but then again, why would a 26 weeker need a heplocked IV unless they were getting blood. And it said there were others affected. I find it odd that that many babies would require heparin locks for piv's that would clot with ns flushes.

lovemyjob · Sep 21, 2006

When i was on staff-we had all additives on the unit and we made all our fluids and drips- D10 with CA, Kcl, dopamine etc.quote]
That sounds too scary...

denicu · Sep 21, 2006

When i was on staff-we had all additives on the unit and we made all our fluids and drips- D10 with CA, Kcl, dopamine etc.quote]
That sounds too scary...
Actually it wasnt scary at that time. I started in the unit as a gn and worked there for 14yrs-it was a very busy unit but we had excellent nurses and the unit was very team oriented. As for medication error-im sure we had some but none critical. Now i work agency and i have worked in many nicu's, but i follow their protocol for care and when i am in Rome i do as the romans do.

Jolie, BSN · Sep 21, 2006

As an agency nurse in nicu i have seen heparin come up from pharmacy to flush heplocks. Other hospitals i have worked-there are no additives on the floor eg Kcl, Ca etc and pharmacy makes just about all the medications. Another unit i work in-pharmacy makes up all the antibiotics(vanco, claforan gent) etc in 1 bag so everyone can draw from it. That made me a little nervous because i remembered a few yrs back pharmacy made up flushes and added kcl instead of ns and 3 babies died. When i was on staff-we had all additives on the unit and we made all our fluids and drips- D10 with CA, Kcl, dopamine etc. I think 2 nurses checking a medication before its given is a good idea and i hope most hospitals will change to doing that.

I worked in a NICU a number of years ago where a common flush bag was prepared in the morning for use by all nurses for 24 hours. I thought the practice had long since been abandoned in favor of pre-made flushes from pharmacy, for greater safety and improved infection control, but maybe not. I don't know if this is what happened, but it could explain how the error of 1 or 2 nurses and/or 1 pharmacy tech could impact so many babies. It also points up another pitfall of medication administration: we must trust that labels are accurate.

BabyNurse513 · Sep 21, 2006

I thought heplocking pivs was a thing of the past. I have only heplocked a piv when I worked in a nursery and the lines kept ctotting between abx doses and the cjild was a very difficult stick. We only use 1/4ns for flushing piv's and we flush every 4 unless there are fluids running. When when I was in nursing school our instructors said they were nolonger flushing with hep because it wwas unnecessary, ns would do. The article made it sounds like using heparin was a stadnard (because it was used on several others)....but then again, why would a 26 weeker need a heplocked IV unless they were getting blood. And it said there were others affected. I find it odd that that many babies would require heparin locks for piv's that would clot with ns flushes.

Our policy is to flush all PIV's q8 with heparin. The only exception are the babies that are on ECMO.

Gompers, BSN, RN · Sep 22, 2006

I, too, am surprised at the number of units using heparin for flushes. It just seems like an unnecessary medication, and opens up room for errors like this tragic one. We just use normal saline - we have 3cc flushes that are prepackaged and ready to use. We flush our peripheral IVs with 0.5-1cc of NS about every four hours if there is no fluid running through them. It's extremely rare for us to have a line clot off - usually we lose them because of infiltratin or the catheter slipping out of the tape. Once in a great while we might have a big kid on antibiotics that does clot off IVs, and in those cases we'll have a heparinized saline drip TKO at 1cc/hr - and again, in those cases we use prepackaged IV bags that have 2 units/ml that haven't been altered by pharmacy or anyone. We also check our IV bags and all IV medications with another nurse before infusing them.

The only time we use actual heparin flushes on a baby is when they have a Broviac that is clamped off for hours at a time. This happens maybe once every two years for us, so we're all nervous around them and double/triple check our heparin flushes in those cases since we're unfamiliar with them.

dawngloves, BSN, RN · Sep 22, 2006

Our policy is to flush all PIV's q8 with heparin. The only exception are the babies that are on ECMO.

We don't flush with heparin anymore. When you think about it, flushing with an ml or so of heparin, 3 times a day in a 2 pound baby, is a lot of heparin.

For central lines, our fluids come pre made with heparin added and we flush PIVs with NSS.

Joannie · Sep 22, 2006

The last unit I worked in was a very busy unit and we made up all our own infusions - dopamine, fentanyl, morphine etc, and did our own IV adds (KCL, NaCL, etc) and EVERYTHING was checked by 2 nurses. We had very few errors, and interestingly enough most of those were antibiotics. Weird, huh?

In the last 3 units I have worked in we used 0.45% saline for PIV flushes and flushed Q6H - made no difference at all to how long the IVs lasted.

Just goes to show - check, check and check again. Always.

cathys01 · Sep 23, 2006

If we get a new admission that needs umbilical lines, or if we have a kid that gets a new PICC or PAL, we mix the fluid on the unit, usually 1/4NS with 0.25 or 1 unit of heparin/ml. We probably use 3-5 vials of heparin per day with this practice. The nurses always double check the vial for the concentration (we stock 1000u/ml vials) and double check the amount being drawn up against the order.

So far we haven't had any problems. We also mix our own antibiotics on a new admission (amp, gent, tobra), we mix D10+Ca...we double check everything we hang with another nurse.

We don't heplock PIV's, just NS or 1/4NS, depending on the kid's labs.

steelydanfan · Sep 23, 2006

In my hospital, heparin is one of 7 drugs that require a 2 nurse check prior to administration. We stock 1,000u, and 10,000u vials in our pyxis, hence the need for check.

Is this not the case in other hospitals?

Jolie, BSN · Sep 23, 2006

In my hospital, heparin is one of 7 drugs that require a 2 nurse check prior to administration. We stock 1,000u, and 10,000u vials in our pyxis, hence the need for check.
Is this not the case in other hospitals?

What is the purpose of stocking 10,000u vials in the NICU? If you are mixing a 1L bag of IVF, you would only need 1000u at most, so having 10,000u vials seems like an unnecessary risk.

Just curious.

P.S. What are the other 6 drugs?

RainDreamer, BSN, RN · Sep 23, 2006

Wow, that is so incredibly sad My heart goes out to those families, how tragic.

We never heplock PIVs either. There's heparin in the TPN and we just flush the saline-locked PIVs with 1/2 NS and never have a problem with them clotting off.