Babies given wrong dose of Heparin @ Cedar Sinai - page 5

I'm a new nurse and haven't worked in a hospital setting yet, but I was under the impression a lot of facilities were getting away from heplocks and using saline locks instead??? ... Read More

  1. by   MrsWampthang
    Quote from Suesquatch
    Okay, I am missing something.

    A unit in insulin generally equals a ml. So how big would a freakin' syringe have to be to contain 10,000 u of hep?

    What am I missing?

    And who just grabs big, honkin' syringes and starts whacking teensy babies with 'em? I don't care where the aide alledgedly left 'em.
    Now I'm missing something. I gave 1 unit of insulin subq injections all the time, which was like 0.01 of a 1ml insulin syringe, 10 units was 1/10 of an ml and given subq. Where do you work that you would give 10 units of insulin in a 10 ml syringe and how did you give it?

  2. by   SuesquatchRN
    Quote from DutchgirlRN
    Recheck those syringes Sue...An insulin syringe holds 1 ml of insulin which is 100 units.
    Yeah, I know that. I always screw it up when I say it. Thanks, though.

    The apples and oranges thing - yeah, bad comparison, I know. But I needed a frame of reference I could wrap my head around and this worked. I've never given a heparin injection, just Lovenox, and that comes pre-filled and ready to go.


  3. by   labcat01
    Quote from prmenrs
    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 hear what you are saying and I completely agree! I'm sure the manufacturers feel that changing the packaging would be seen as an admission of guilt. I wish there was more public outcry about this
  4. by   caliotter3
    The company could always wait until in-between mishaps and change the packaging with no public announcements. It's their problem that the packages are this way, they can fix it whenever they choose and state that they intended to do so anyway if they say anything at all. They choose not to do so. Thick-headed wrong thinking. Any facility that stops doing business with Baxter is making the right move IMHO.
  5. by   MA Nurse
    Not sure if there was a thread started about this yet. Recently, Dennis Quaid had twins. They went to the hospital for a staff infection and were given the 10,000 unit heparin/cc to flush their lines instead of the 10 unit heparin/cc. Now the Quaids are suing the drug company because the 2 vials look so similar.
    Do you use the 10 unit/cc heparin in your unit? We don't. I'm glad. We use a pre-mixed bag made by pharmacy that comes 1/2u heparin/cc in normal saline. I've heard that the 10 unit/cc isn't really necessary, especially in low birth-weight premies. We used to use 10 units/cc at my other job, but only if the baby was over a certain weight.
    Just curious if you have to deal with different heparin vials, I find this very scary. I hope the drug company changes their packaging and more hospitals just stop using it...and use a smaller dose like we do.:uhoh21:
  6. by   elizabells
    We use saline to flush PIVs. For our PICCs and Alines, we use 1:1 heparin premixed by pharmacy. The ONLY time I have ever drawn heparin from a vial was to anticoagulate a baby during the ECMO cannulation process. For the heparin drip on the ECMO pump, they use something like 60U/cc? It comes in a syringe, again mixed by pharmacy.
  7. by   Lindz
    I don't work NICU, but peds med/surg. Our omnicell is stocked with prefilled 10 unit and 100 unit (for ports) heparin. The 10's are bright blue and the 100's are bright yellow and they are stocked on different shelves of the omnicell. You'd have to be blind to mix the two up.
  8. by   MA Nurse
    Quaid is claiming that the 10 unit and 10,000unit are both packaged in the same way and both have a blue label...that's why he's suing.
  9. by   elizabells
    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.
  10. by   RainDreamer
    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.
  11. by   BittyBabyGrower
    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.
  12. by   dawngloves
    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.
  13. by   sirI
    Threads merged.