Baxter (Makers of Heparin) being sued. - page 5
Actor Dennis Quaid and wife Kimberly Buffington have filed suit against Baxter Healthcare Corp., the makers of the drug Heparin. The couple's newborn twins Zoe Grace and Thomas Boone were... Read More
Dec 6, '07Occupation: Endocrinology Specialty: 15 year(s) of experience in ER ; From: US ; Joined: Sep '02; Posts: 179; Likes: 127What ever happened to the five rights? RIGHT DRUG! tHOUGH SAFETY IS A MAJOR CONCERN NEGLIGENCE ON THE PART OF THE NURSE IS NO EXCUSE! Right drug Right drug right drug!
Dec 7, '07Joined: Jan '05; Posts: 4,765; Likes: 2,554Quote from evilnightwitchWhat ever happened to the five rights? RIGHT DRUG! tHOUGH SAFETY IS A MAJOR CONCERN NEGLIGENCE ON THE PART OF THE NURSE IS NO EXCUSE! Right drug Right drug right drug!
Ugh...do people even read these threads before they post anymore?
Yeah, the five rights have been covered already. Thanks...
Oh, and it was the the right drug. We are discussing the dosage.
Dec 7, '07Specialty: 5 year(s) of experience in ICU, telemetry, LTAC ; Joined: Apr '04; Posts: 1,483; Likes: 1,003It's true that people are trying to change from witch hunt mentality to "systems error" mentality, but sometimes people do fall back on the old way of thinking. Yes, the person who gives the med is the last link in the chain, and the last person who can prevent an error, therefore that person will seem like the one who shoulders the most responsibility for the error. But that one person, the nurse, is still part of a system that creates the error. To fix things you have to look at the system.
And Gwenith is right; when you're in a hurry you see what you want to see no matter how many times you look at it. I've made errors that way. Most of the time I'm lucky in that I check, double check and voila! Find the problem and do the right thing. You know there's a brand of Haloperidol that is packaged almost exactly like a vial of injectable B-12. Very interesting. The pharmacist at my first job mixed those two up TWICE and twice I caught it and avoided an error of administration. However, who knows how many psychotic old ladies on ambien accidentally got B-12 IV? Even though B-12 is a red liquid...
Hey, it could happen.
I'm pleased to see that the ICU I work at now stocks haloperidol in a vial that looks nothing like the B-12. Nice. It's good that it's made that way, and it's good that the pharmacy thought to do this. Plus they made it a "you gotta count it" drug in the omnicell and yeah, it's not a narcotic but you have to pay a little extra attention to the things so maybe that helps. I hate counting stuff that isn't narcotic but in this case I'll make an exception.
Let's examine another one. "change IVF rate to XXml/hr." is what the order said. The patient was just prior to being extubated, was very sick, there was family drama everywhere, the doc was standing right next to me. I told him what fluid was hanging and said, "is that ok?" He said, sure. I read the order and did my chart check. Each time I read it I could have sworn to you that the order specified the fluid. Since I thought that, I didn't write any verbal order for what was hanging. Nor did it occur to me to wonder why the original order, pages back, was for something else.
Haha, well I got the dayshift nurse yelled at for my mistake. The patient was not in any different condition than he would have been with different fluids, but the doc wasn't happy. That's one person not listening to me, and me seeing what I wanted to see. It happens in medicine all the time. The systems can, and do break down, and very seldom do errors involve someone who doesn't even try to follow the 5 rights.
People don't need to even think about getting on a high horse. Errors are serious, and errors kill people sometimes. Sometimes better staffing can help in that it can give nurses time to do their jobs right. Sometimes it's packaging of the materials themselves. Sometimes it's the way the pharmacy arranges their stuff on their shelves... they are human and can send you the wrong stuff, and I guarantee you pharmacists don't go to work with the intent to not read labels and cause errors either. What I like about this case is that it seems to me the parents seem to have realized that the people taking care of their twins were really trying to take care of their babies properly; so they're choosing a path of action that will help prevent this from happening again.
Dec 7, '07Specialty: ICU,PCU,ER, TELE,SNIFF, STEP DOWN PCT ; Joined: Sep '07; Posts: 128; Likes: 148Quote from evilnightwitchThank you, that is what I was thinking.What ever happened to the five rights? RIGHT DRUG! tHOUGH SAFETY IS A MAJOR CONCERN NEGLIGENCE ON THE PART OF THE NURSE IS NO EXCUSE! Right drug Right drug right drug!
Dec 7, '07Occupation: Nurse Educator Specialty: 13 year(s) of experience in NICU ; From: TX, US ; Joined: Nov '05; Posts: 8,750; Likes: 1,692We can second-guess this situation all we want, but at this point it should be about preventing future harm to babies, not about pointing fingers.
In preventing future incidents, sure, we can try to demand perfection from each one of thousands of nurses, each time, even under what can be incredibly stressful circumstances.
However, I think making this single change in packaging is probably a good idea, too.
Dec 7, '07Joined: Oct '04; Posts: 5,969; Likes: 1,404Quote from EricEnfermeroThank you!!but at this point it should be about preventing future harm to babies, not about pointing fingers.
People are so hell bent on placing the blame, they fail to see what the end result should be in all of this. The nurses and pharmacy were held at fault in the past and yet errors are still occuring. So it's time to look at the root of the problem. Period.
Dec 7, '07Occupation: Utilization Review, prior Intake Mgr Home Care Specialty: 40 year(s) of experience in Home Care, Vents, Telemetry, Home infusion ; From: PA, US ; Joined: Oct '00; Posts: 27,596; Likes: 13,850the institute for safe medication practices does a fantastic job to decrease and prevent medication errors.
from their website:
from the november 29, 2007 issue
another heparin error: learning from mistakes so we don’t repeat them
it’s been headline news for the past week: three infants at one of the most reputable hospitals in california received 1,000 times more heparin than intended when vials containing 10,000 units/ml instead of 10 units/ml were used in error to flush the infants’ vascular access lines. no doubt the intense media attention given to these errors is related to the fact that two of the infants are the newborn twins of hollywood celebrities dennis and kimberly quaid. fortunately, according to news reports, none of the affected infants suffered lasting adverse effects from the error.
these events are remarkably similar to a case in indiana last year that we described in our september 21, 2006 newsletter. in that case, three babies died after receiving overdoses of heparin while flushing their vascular access lines. according to news reports, in both the indiana and california cases, pharmacy technicians accidentally placed vials containing more concentrated heparin (10,000 units/ml) in storage locations in patient care areas designated for less concentrated heparin vials (10 units/ml). vials (both from baxter, according to the media) containing the different strengths of heparin looked similar. thus, the nurses—who were accustomed to finding only the 10 units/ml concentration of heparin in stock—did not notice the error until after the wrong concentration had been used to flush the infants’ access lines.
in response to the most recent error, the california hospital no longer stocks heparin 10 units/ml vials in pediatric units and uses saline to flush all neonatal, pediatric, and adult peripheral lines. no information was shared about flushing practices for central line catheters, including umbilical lines and picc lines. in the pharmacy, 10,000 units/ml heparin vials have been separated from vials containing other strengths.
in our september 2006 newsletter article, we made additional recommendations, which included: verifying all drugs pulled in the pharmacy for restocking in patient care units; using bar-coding to verify the drug and strength; and replacing heparin vials with prefilled syringes of heparin flush solutions. low-dose heparin flush syringes are available from hospira in 1 unit/ml (3 units/3 ml per 10 ml syringe) and 2 unit/ml (6 units/3 ml per 10 ml syringe) strengths.
recently, baxter revised the packaging and labeling on its 1,000 units/ml, 5,000 units/ml, and 10,000 units/ml heparin vials. distribution of the newly labeled vials began in october. unfortunately, vials with the old labels are still part of the inventory in many hospitals. if you currently stock baxter’s 10 units/ml vials along with vials containing other concentrations, request products with the new labeling as soon as possible. baxter representatives informed us that they are ramping up inventories and pursuing alternatives to accelerate manufacturing and distribution to meet anticipated needs.
a deeper analysis of these heparin errors underscores two fundamental problems in today’s healthcare industry that continue to threaten patient safety:
- our failure to fully adopt a learning culture
- our failure to be truly mindful about safety...
ismp injectable syringe labels ---check to see if meds you use meet these guidelines. if not, speak up to your pharmacy staff.
lastly, subscribe to:
ismp medication safety alert! nurse advise-err is designed to meet the medication safety information needs of nurses who transcribe orders, administer medications, and monitor the effects of medications on patients. published monthly, the newsletter offers detailed error reports and checklists of evidence-based error reduction strategies. nurse advise-err is being offered free to all nurses during 2007 through an educational grant from mckesson corporation.Last edit by NRSKarenRN on Dec 7, '07
Dec 7, '07Occupation: ED Nurse Specialty: 10 year(s) of experience in Emergency Dept ; Joined: Jul '06; Posts: 280; Likes: 235Quote from CoolhandHutchEXACTLY!!!I'll disagree with the idea that the lawsuit is a good idea. It's not Baxter's responsibility to ensure proper administration of their medication- it starts with the pharmacy and trickles down to the nurse. It is a dangerous practice to administer medications based upon the color of the vial top or labeling or other 'visual aids'. The label on the medication needs to be read and compared with the order- not a cursory glance at the color of the top or the packaging that we typically expect. The USA Today article nails it on the head where the responsibility is:
5 rights anyone?
Yeah, it would be good of Baxter to change the bottles to make them look massively different, but the pharmacy staff did not do their job, and neither did the nurse(s). We learn the 5 rights in Day 1 of nursing school. And I don't know about other hospitals, but at ours we have to be checked off every year about Heparin administration because it can be such a dangerous drug.
Dec 7, '07Joined: Oct '04; Posts: 5,969; Likes: 1,404Quote from cardiacRN2006:yeahthat:Ugh...do people even read these threads before they post anymore?
Yeah, the five rights have been covered already. Thanks...
Oh, and it was the the right drug. We are discussing the dosage.
Dec 7, '07Joined: Mar '06; Posts: 3,901; Likes: 6,772Sure, the bottles both have blue labels although the caps are different colors. I guess Baxter can pick different colors for the labels but how many drugs are packaged in the same size bottle? I'm an 8 crayola kind of guy. Even if you went with a 36 crayola box you'd run out of colors long before we had all the different meds/dosages labeled. Don't forget, sometimes a totally different drug gets dropped into the wrong slot in the pyxsis. A blue top phenergan bottle looks a lot like this heparin bottle if you don't read the label.
I think more blame lies with the pharmacy techs and nurse in this case. The primary way to identify a drug is to READ the label. Maybe I've not been a nurse long enough but I read the label for every drug I give and every fluid I hang. I don't rely on it having black lettering or a grey top. Our ketorolac has different color tops depending on which manufacturer was cheapest to purchase from this week.
Dec 7, '07Joined: Jan '04; Posts: 999; Likes: 1,020Quote from RainDreamerit's time to look at the root of the problem. Period.
Nurses that don't read the labels of the drugs they give is the root of the problem.
Dec 7, '07Joined: Oct '04; Posts: 5,969; Likes: 1,404Quote from november551That's the root of the problem? Yet, if the labels were different, then the pharmacy would have most likely never even stocked the wrong drug on the unit. But if they did, the nurse would have looked more closely at it, keeping this from happening as many times as it did.Nurses that don't read the labels of the drugs they give is the root of the problem.
I'm not saying the nurse wasn't in the wrong. She was, obviously. But we can slap the nurse on the hand, make her take a class, review the 5 rights of medication, etc. ...... and then this will happen again in a few months. Or we can put safety measures into place that keep this from happening as often as it's been happening.
If it were my child in the hospital that could potentially be harmed, then I would want all the safety measures put into place that were available. I would want to know that everything was being done, from all sides, to make sure this doesn't happen again.Last edit by RainDreamer on Dec 7, '07
Dec 7, '07Joined: Mar '06; Posts: 3,901; Likes: 6,772The bottles were different shades of blue and had totally different colored caps. There's a link in a message on the first page of the thread which shows the bottles in question. Even if the colors were changed, some nurses could be colorblind which negates the benefit of different colored labels.
However, they could put barcodes on the labels and require us to scan in the med and enter the dose. That would catch the wrong product in the wrong bin error for the floors, as long as the meds are all entered into the system correctly. I would just hope they continued to put the med information on the labels for those who read labels. When my child is in the hospital, I want pharmacy techs and nurses who read labels. To me that is pretty basic. How would a nurse know that heparin is in a blue bottle if they didn't read the bottle at least one time?