Medication error causes 2 deaths in Indiana NICU

RainDreamer, BSN, RN · 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?

We are required to double check ALL of our meds with another nurse.

Mimi2RN, ASN, RN · Sep 23, 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.

Saline locks work well with 22g and bigger IV catheters. 24 g caths will clot off. Our pharmacy draws up syringes of heparin and deliver the hep flushes to our med refrigerator, accessed through the pyxis. I can't rember how much heparin is in the syringes, but it's a saline/heparin mix.

It's possible that the babies had dual lumen UVC's, and only one lumen had IV fluids. The other lumen would need flushing after use or q 4-6 hrs, whatever their protocol. I like to double spike the IV fluids, and use both lumens.

I read the rest of this, and I'm surprised how many of you do keep lines open with just saline!

Gompers, BSN, RN · Sep 23, 2006

Saline locks work well with 22g and bigger IV catheters. 24 g caths will clot off. Our pharmacy draws up syringes of heparin and deliver the hep flushes to our med refrigerator, accessed through the pyxis. I can't rember how much heparin is in the syringes, but it's a saline/heparin mix.
It's possible that the babies had dual lumen UVC's, and only one lumen had IV fluids. The other lumen would need flushing after use or q 4-6 hrs, whatever their protocol. I like to double spike the IV fluids, and use both lumens.
I read the rest of this, and I'm surprised how many of you do keep lines open with just saline!

If we have double lumen lines, we keep them open by running 0.3-1 cc/hr (depending on size of the baby) of heparinized saline - either 0.45 or 0.9%, with 2 units of heparin/cc. The 0.45 bags are made by pharmacy and the 0.9 stock bags are premade by the IV bag company.

Like I said before, we rarely see peripheral IVs clot off unless it's a really big baby. Usually they just infiltrate or slip out.

KRVRN, BSN, RN · Sep 23, 2006

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.
The problem was that they weren't usually stocked with 10,000 unit vials. So when the pharmacy stocked 10,000 unit vials where the 100 unit vials usually were the nurses accidently used the wrong concentration. And I heard something about the labelling being a similar color too.

lovemyjob · Sep 23, 2006

Saline locks work well with 22g and bigger IV catheters. 24 g caths will clot off. Our pharmacy draws up syringes of heparin and deliver the hep flushes to our med refrigerator, accessed through the pyxis. I can't rember how much heparin is in the syringes, but it's a saline/heparin mix.
It's possible that the babies had dual lumen UVC's, and only one lumen had IV fluids. The other lumen would need flushing after use or q 4-6 hrs, whatever their protocol. I like to double spike the IV fluids, and use both lumens.
I read the rest of this, and I'm surprised how many of you do keep lines open with just saline!

We only use the 24g iv's and we dont have any probs with them clotting if flushed q4 (micropreems, preems and termers). If it is known to clot on a certain difficult stick, we may decid eto flush q2 or so. only use piv's for blood products or until picc or other lines can be placed. We reallyOur docs usually write to run HAL split if it is a double lumen uvc or double lumen picc (wich we dont use too often.) our policy states that if fluids are stopped on a picc or any other central line it either has to be pulled ot run at kvo. if it runs at kvo it has 1/4ns with 1:1 heparin running at 0.5 or 1. I thik they are just looking to keep down the number of times the line is accessed and also decrease chance of micro emboli.

NICU_3_RN · Sep 25, 2006

The problem was that they weren't usually stocked with 10,000 unit vials. So when the pharmacy stocked 10,000 unit vials where the 100 unit vials usually were the nurses accidently used the wrong concentration. And I heard something about the labelling being a similar color too.

you actually don't need heparin in any peripheral IV for flushing purposes. There's been plenty of studies on that fact. We actually flush q8 on my unit with NS, and have no problems with PIVs clotting off. And we use only 24g PIVs.

And the bottom line problem in this case was that the nurses didn't check the label. coloring, size or "whats usually stocked there" be damned... WE as nurses are the last line of defense for these babies. If we're not protecting them, no one else is going to. We're all taught the 5 rights for a reason. Not checking them, no matter how busy you are, is recipe for disaster, as proven in this tragedy.

stevierae · Sep 25, 2006

no excuses. this is nursing 101, and spelled out in the ana code of ethics and most states' nurse practice acts---each person is responsible for his or her own actions. also from nursing 101--the 5 (nowadays, i think more than 5 are taught) rights of medication administration. and, lastly, from nursing 101--always, always, always check your heparin and insulin with another rn or physician before giving.

heparin vials are also color-coded according to strength.

they'll blame this, of course, on "systems error," rather than accepting individual accountability.

here's a different article that provides a bit more detail about this tragic incident:

fatal drug mix-up exposes hospital flaws

by tom davies, associated press writer fri sep 22, 3:55 pm et

indianapolis - early last saturday, nurses at an indianapolis hospital went to the drug cabinet in the newborn intensive care unit to get blood-thinner for several premature babies.

the nurses didn't realize a pharmacy technician had mistakenly stocked the cabinet with vials containing a dose 1,000 times stronger than what the babies were supposed to receive. and they apparently didn't notice that the label said "heparin," not "hep-lock," and that it was dark blue instead of baby blue.

those mistakes led to the deaths of three infants. three others also suffered overdoses but survived.

now, their families, hospital officials and prosecutors are asking the same question: how could this happen?

experts say last weekend's overdoses at methodist hospital illustrate that, despite national efforts to reduce drug errors, the system is still fragile and too often subject to human error.

"i see what happened here as depressingly normal," said dr. albert wu of johns hopkins university, co-author of an institute of medicine report that estimated more than 1.5 million americans a year are injured from medication errors in hospitals and nursing homes and as outpatients.

methodist hospital officials said they had safeguards in place before saturday's overdoses.

hep-lock — a lesser dosage of heparin that is routinely used to keep intravenous lines open in premature babies — arrives at the hospital in premeasured vials and is placed in a computerized drug cabinet by pharmacy technicians.

nurses must enter their employee code and the patient's code into the cabinet's computer to open it. a drawer containing a large variety of medicines then opens, and they select the prescribed drugs from compartments and enter the amount withdrawn.

the system locks immediately afterward to prevent multiple withdrawals for the same patient. but there is no automated system to prevent nurses from taking the wrong medicine from the drawer in the first place.

according to hospital officials' account, a pharmacy technician had loaded the cabinet with heparin, at 10,000 units per milliliter, instead of hep-lock, at 10 units per milliliter.

d'myia alexander nelson and emmery miller died within hours of receiving the heparin. a little girl named thursday dawn jeffers died late tuesday. no autopsies were performed, but hospital officials said the cause of death was probably internal bleeding.

even before the overdoses, the babies faced challenges. d'myia and emmery both weighed about a pound and were born more than three months early, barely past the point where survival is possible. thursday dawn was three weeks premature and, by comparison, a robust 4 pounds, 6 ounces.

d'myia's grandmother lena nelson said the little girl had gained weight in her first four days, then died several hours after she was given the blood-thinner overdose.

"she was doing fantastic. i could see her growing right in front of my eyes," nelson said. "then she was taken from us."

hospital officials adopted new safeguards to prevent a recurrence. among them are procedures requiring a minimum of two nurses to verify any dose of blood thinner in the newborn and pediatric critical care units. another system, using bar codes to track medications, was being developed before the overdoses and is still in the works.

since 2004, the

food and drug administration has required that drug makers place supermarket-style bar codes on their drugs. many hospitals have installed bar-code scanners to make sure medication matches the recipient and is given at the right time. but money is an issue for many — the technology can cost millions.

marion county prosecutor carl brizzi said his office will investigate the deaths, but he is not assuming a crime occurred. the county coroner also is reviewing the case.

methodist president and chief executive sam odle said the hospital planned no disciplinary action against those involved. "whenever something like this happens, it is not an individual responsibility, it's an institutional responsibility," he said.

the five nurses and pharmacy technician involved are on leave and receiving support and counseling, and are expected to return to work, odle said.

nathaniel lee, an attorney for the jeffers and miller families, said the drugs' maker needs to change how it labels heparin and hep-lock. methodist has acknowledged two other heparin mix-ups involving babies in 2001, and said both infants recovered.

"if this was an isolated incident i would say that it would be solely the responsibility of the person at the hospital," lee said. "but this is not an isolated incident."

erin gardiner, a spokeswoman for deerfield, ill.-based baxter international, said the two drugs had different cap and label colors, bar codes and printing.

wu, with johns hopkins, said the oversight was understandable, given that nurses were accustomed to having only the hep-lock vials stocked.

"if someone suddenly were to switch in your home where something was located, rearrange where your furniture was located, it would be really easy for you to trip and fall," he said.

the surviving babies face no remaining danger from the overdoses, methodist spokesman jon mills said.

that is little consolation to thursday dawn's mother, heather jeffers, who blames the nurses, not drug labeling, for her daughter's death.

"i don't think it was from the label," she said. "they are both blue, but one is lighter than the other. how could they mistake those?"

___

dawngloves, BSN, RN · Sep 26, 2006

Here's another take on it:

Nursing Shortage and Hospital Medical Errors

mrmag · Sep 26, 2006

We all agree these medication errors are a tragedy. Human error occurred at many steps in the process: the pharmacy technician placing the wrong concentration of heparin (10,000 u/mL, instead of 10 u/mL) in the medication tray, the multiple nurses not checking the vial label, not having a 'double check' procedure in place in the NICU or in the pharmacy. I also question the frequency and volume used to 'heparin lock' the IV access. The volume required to 'hep lock' vascular access in NICU patients is extremely small. Even with a high concentration of heparin if the amount of heparin administered in the catheter was the volume required to 'lock' it, the patient would have had very little circulating in his/her blood stream. Low volume low concentration pre-filled heparin syringes may have helped to avoid this tragedy.

mrs.mac · Sep 27, 2006

This story is very sad. I think that some (not all) nurses become too confident whether they have several years or very little experience and just don't go back to the basics for things such as checking drugs. Right time, dose, patient, route and of course the right drug..wasn't this what we were taught at nursing school? At the end of the day we are responsible for our own practice and need to protect our patients and outselves from mistakes. :nurse: