Error kills 2 infants in Indiana - page 3

INDIANAPOLIS - Two premature infants died and a third was in critical condition after being given adult-size doses of medication, prompting hospital officials to review drug-handling procedures.Adult... Read More

  1. by   Jolie
    I have worked in NICU's (long ago) where a 1L bag of IVF would be mixed in the morning to contain 1u heparin/cc, and used as a "common" flush bag for the entire unit for the day.

    I assumed (perhaps incorrectly) that this practice had long since been abandoned in favor of individual pre-made doses from pharmacy, for improved safety and infection control.

    I don't know if this is how this error occured and affected so many babies, but it is a possibility. If 2 nurses made an error in mixing and labeling the flush bag, then everyone who drew from it would have exposed their babies to an overdose of heparin. Just one of the dangers of administering medications - we are forced to trust that the label is correct.
  2. by   ClinInfCoord
    this is very sad, and examples such as these are the very reason that our facility is implementing a new medication administration system, called bmv, or bedside medication verification. bmv simply ensures that every patient and every med have a barcode. when the patient arrives at our facility, they receive an armband with a unique barcode. as the doctor orders medication for the patient, the order is routed through pharmacy, who puts that information in the computer and "profiles" those specific meds/doses, etc. for the patient. we do all of our documentation on computers, so the nurse will pull the med(s) from pyxis, take the meds to the patient's bedside along with the "cow" (computer on wheels), and then proceed to scan with a laser scanner the barcode on the med and then the barcode on the patient's armband. if any of the 5 med rights are out of sync...i.e. wrong dose, wrong route, wrong drug, wrong patient, etc., a warning message automatically pops up on the computer screen alerting the nurse...essentially and potentially saving the patient's life. had this particular system been in place at the facility in indiana, and had the nurse used it, then it would have alerted the nurse that the dose was wrong for the babies, and the med most likely would not have been given. many, many facilities nationwide have either implemented a similar bmv system or are in the process of implementing one. it is an extra safe measure, and most nurses i have talked with, myself included, feel much safer giving meds with this system in place. i urge any nurse out there giving meds to ask your administrators to look into implementing this type of system, if one is not already in place. if one is, please use it!

    ******to err is human...to prevent is divine!*******
  3. by   standswithfist731
    That's why I am not a peds nurse. Those meds(any of them scare the hell out of me) I just could not live with myself. I wonder if any disciplinary action will be take by the nursing board....








    /
  4. by   Reeda
    a third baby died today. it sounds like 2 of the families are pressing charges. will the hospital cover the nurses or do the nurses need to defend themselves in court?
  5. by   HARRN2b
    On the news today they said it was the fault of a pharmacy tech. Also a girl I know works at Methodist and she said they use arm bands. She said they had recently installed the new computer systems to prevent errors like this. Anybody hear any other information?
  6. by   Jolie
    Quote from clininfcoord
    this is very sad, and examples such as these are the very reason that our facility is implementing a new medication administration system, called bmv, or bedside medication verification. bmv simply ensures that every patient and every med have a barcode. when the patient arrives at our facility, they receive an armband with a unique barcode. as the doctor orders medication for the patient, the order is routed through pharmacy, who puts that information in the computer and "profiles" those specific meds/doses, etc. for the patient. we do all of our documentation on computers, so the nurse will pull the med(s) from pyxis, take the meds to the patient's bedside along with the "cow" (computer on wheels), and then proceed to scan with a laser scanner the barcode on the med and then the barcode on the patient's armband. if any of the 5 med rights are out of sync...i.e. wrong dose, wrong route, wrong drug, wrong patient, etc., a warning message automatically pops up on the computer screen alerting the nurse...essentially and potentially saving the patient's life. had this particular system been in place at the facility in indiana, and had the nurse used it, then it would have alerted the nurse that the dose was wrong for the babies, and the med most likely would not have been given. many, many facilities nationwide have either implemented a similar bmv system or are in the process of implementing one. it is an extra safe measure, and most nurses i have talked with, myself included, feel much safer giving meds with this system in place. i urge any nurse out there giving meds to ask your administrators to look into implementing this type of system, if one is not already in place. if one is, please use it!

    ******to err is human...to prevent is divine!*******
    barcoding and other systems are imortant steps in improving patient safety, but it is unwise to think that they can or will prevent all errors. if pharmacy inadvertently barcodes the wrong medicine, it will still be possible to administer the wrong drug to your patient.

    i would venture a guess that this hospital probably has a barcode system in place, as it is becoming the norm in most institutions.

    human error is always a possibility, regardless of the system in place.
  7. by   jna724aj
    I've skimmed through many comments blaming the pharmacy tech involved in this case. I have been a pharmacy tech for many years (and even worked full-time as one through nursing school).
    Now an RN, I have much respect for both the pharmacy and nursing department. We must collaborate with different parts of the health team in order to maximize patient outcomes.
    This was truly a very sad case . Regardless of work volume and/or how busy each of the departments can be...one thing for sure was not done by either party ....the one thing that was always stressed in nursing school and the pharmacy tech program....READ THE LABEL THREE TIMES!!
  8. by   mary4mary
    The drug company is at fault for the similar packaging
    The pharmacy is at falut for dispensing the wrong dose vials
    The Nurse is at fault for not reading the label, not reading the med sheet or not knowing the correct dose.
    The hospital is also at fault for proceedures that made the error possible. This is horrible and I hope all the families file law suits against all of them
  9. by   RebeccaJeanRN
    I was so saddened to hear of the third baby dying. Also, not to be overly suspicious and cynical...ahem...but I found it surprising that the hospital was so quick to stand by the nurses...then subsequently I heard that it might have been a pharmacy error and couldn't help but to think "so that was why!". Those poor nurses! Those poor parents! Those poor, poor babies!
  10. by   mareekha
    I totally agree with you; we get in such a hurry and take for granted that what is in there is what it is supposed to be. I can see it happening to me when I get to rushing; this is an eye opener and a warning to heed. And I agree, our GOD is an awesome GOD!
    Mareekha
  11. by   mareekha
    Quote from RebeccaJeanRN
    I was so saddened to hear of the third baby dying. Also, not to be overly suspicious and cynical...ahem...but I found it surprising that the hospital was so quick to stand by the nurses...then subsequently I heard that it might have been a pharmacy error and couldn't help but to think "so that was why!". Those poor nurses! Those poor parents! Those poor, poor babies!
    If I understand the situation, the pharmacy person placed 10,000 u/ml in the spot where the pediatric dose should have been. Ultimately, though, when we pull out the med, we are supposed to read the label, so you know who will get most of the blame. I hope the nurses get the emotional support they need, as GOD knows they will mentally punish themselves enough for an army. I can't imagine.
  12. by   mareekha
    Quote from Jolie
    Barcoding and other systems are imortant steps in improving patient safety, but it is unwise to think that they can or will prevent all errors. If pharmacy inadvertently barcodes the wrong medicine, it will still be possible to administer the wrong drug to your patient.

    I would venture a guess that this hospital probably has a barcode system in place, as it is becoming the norm in most institutions.

    Human error is ALWAYS a possibility, regardless of the system in place.
    I agree, as I currently work in a facility that uses barcoding. Unfortunately it can be gotten around, and there are certain times when the barcode on bottles won't scan. It is ultimately in the hands of the person using the system.
  13. by   CyndieRN2007
    Does anybody have a link on the news about the third baby that died? What a tragedy. Again, my heart goes out to everyone involved.

close