Error kills 2 infants in Indiana - page 4

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   CyndieRN2007
    Here's the link to the full story article. Hope it works.

    INDIANAPOLIS - The grandmother of a third premature infant who died after being accidentally given an adult-sized dose of blood thinner medication at a hospital said Wednesday that she prayed other families wouldn't go through what she had, because it was hard "to sit there and watch my granddaughter die."
    The baby girl, Thursday Dawn Jeffers, died late Tuesday at Riley Hospital for Children five days after she was born at Methodist Hospital. She had been transferred to Riley once her condition worsened from receiving an adult dose of heparin, a drug routinely given to premature babies. The child's grandmother, Joanna Pruitt, said Wednesday at an emotional, impromptu news conference called at her daughter's apartment that doctors initially told the family that the 4-pound, 6-ounce baby just needed oxygen "to get her lungs going good" after she was born. The infant had been breathing on her own before receiving the drug, she said.
    Last edit by CyndieRN2007 on Sep 21, '06
  2. by   DevelopmentRN
    I can't believe the hospital would blame the pharmacy tech, probably a kid with a high school education. WE are responsible for administering the right medications. WE are the patient's first and last line of defense. There is not a technology in the universe that can substitute for our diligence. Having said that, I am sick for those nurses. I can't imagine what they are going through. If anything good comes of this, it will remind us that overreliance on technology can be deadly for those entrusted in our care.
  3. by   matchstickxx
    Quote from student4life
    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.
  4. by   IndyGal
    Quote from 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?
    I thought I heard on the news that the barcode system is up and running elsewhere but there were delays implementing it in NICU. Don't quote me on that, though -- I was doing something else while the news was on so I might not have heard right.
  5. by   mysticalwaters1
    Aww this was awful! I hate it too b/c you seem to only hear bad stuff about nurses or maybe I'm just negative OR good stuff rarely discussed. Now it sounds like the blame is falling more on the pharmacy tech at least from the news but I have a system at work like this too I believe or at least it's a computer you select the med and the drawer pops open you HAVE to check the med oh my. I felt horrible when I heard the story for the nurse b/c it looked like the dosage wasn't checked! Unless it was a mixed thing but looks more like a standard dose that you can read the dosage right on the bottle. I know we are busy and I caught myself continually giving asa from cp when I realized I looked at the pill and not the label one time and thought oh jeeze and made sure to check the label which it was but caught myself going with the motions almost how easy it is to do. And there has DEFINITELY been incorrect filling of the machines by pharmacy. And it's just human error. But you have have got to check the dosage this is horrible! I don't find it too often but in a year about 3 things I found and reported to pharmacy immediately and it's fixed. One time in the tylenol sup there were tigan sup. And one time a cardiac pill in for a diabetic pill. But stories like this just show you how important it is to look at your med. I remember a nurse complaining about narcotics not placed in the right order before our computer when it was locked in a cabinet and said somebody could pull a box out and pull the wrong med and give it. Well you cannot do that you allways look at the med. Who knows what could happen. Sometimes that's questionable too the packaging! You can't go by colors on a bottle. Or you can but still check the name and dosage. I'm surprised not more attention is drawn to the nurse. I'm not trying to be harsh but that was my first reaction but it is an entire system too involved but we are the last in the chain before the med is received!

    This is just horrible for everyone involved!
  6. by   mysticalwaters1
    Also, barcoding and computer orders has issues too. My hospital one time the written md orders was typed in a chart but the paper in it had a different pt stamp so right chart, wrong paper work in wrong chart scanned to pharmacy and as a result one nurse found orders on her computer for meds to give. She confirmed the order before double checking the paper orders. So she gave a med never ordered for the pt had to call the dr. just tessalon pearls pt was fine. But sheesh. I think in this case it's to confusing with part written orders transfering to computer. Orders are mixed up lost, old orders and new orders not overiding old orders so there's duplicate orders. Agh... I think once our mds have computer order entry this aspect will run smoother. Not to mention help with illegible handwriting! A lot of our mds don't want to use it. I hate this. One of the best classes I took in HS was keyboarding. Even then I didn't realize how much computers would be involved with charting. But getting there is cumbersome too much can be mixed up trying to transfer everything to accomadate everyone. Even our old charts are becoming on a computer. I don't have access to it and working in the ED now it's so darn frustrating when pt's don't know med list and the md want's me to look it up when they have computers at home with full access at their fingertips and demanding I do something about it. Going off track here sorry!
  7. by   mysticalwaters1
    Quote from mysticalwaters1
    Also, barcoding and computer orders has issues too. My hospital one time the written md orders was typed in a chart but the paper in it had a different pt stamp so right chart,

    Sorry that's hand written not typed. And what happened to the edit button? I'm typing a gazillion posts now sorry!
  8. by   mysticalwaters1
    Quote from mareekha
    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.
    I would think so as well.
  9. by   IndianapolisNurse
    I work for Clarian Health Partners, and we have been receiving emails from the president regarding this incident. When I first heard of it, I was in shock! I can't imagine how everyone involved feels..From what I have been told and from what I have heard on the news and read in newspapers over here in Indiana...apparently a pharmacy tech. with 25 years experience loaded the pyxis (which is a pyxis for NICU only) with the wrong heparin. It was loaded with the adult dosage form 10,000u/ml. There was a picture of the 2 vials in a newspaper, and they looked IDENTICAL except for the doses on the bottles were different. Even the lettering was the same color!!! From there, it was pulled from the NICU pyxis like it has been in the past by the nurses and administered to the preemies as a flush to keep their lines patent. The nurses apparently took for granted that it was the correct dose and obviously didn't perform the 5 rights. It seems that a lot of the blame is geared towards the pharmacy tech over here in Indiana. I too was a pharmacy tech for 3 years before becoming a nurse and from what I have been taught...we as nurses are responsible because we are the ones that actually administer the medications. There was a new computer system installed at Methodist, but it was just a computer charting system. You chart the meds you give on there as well, it's called Cerner...BUT as far as I know..there is no band scanning or anything like that as of yet. I work for Clarian West (which is another affiliate of Clarian Health Partners). We have only been open for a couple years; we have had Cerner charting since opening the doors, but we have no IDband/med scanning capability or anything like that, and we are suppose to have the best of the best in technology. That being said...I don't think that Methodist has anything like that implemented in their hospital that I am aware of.
    My heart goes out to all involved as niece was born premature in that same time frame weighing only 2 pounds 14 ounces...she is in a hospital in IL. but it made me that could have been her if she had been sent to Methodist hospital instead of an IL. hospital. (They live in IL.) It's just an awful feeling and words can't even begin to console any of those individuals involved. I'm sure we will be hearing more on this and as soon as I do, I will keep you all up to date. We were informed that the other 4 preemies were all in critical care, but not due to the Heparin overdose, but just from being premature.
  10. by   mareekha
    I am a traveler working at Clarian North. They have the whole shebang-charting, (Cerner), meds with Cerner Bridge and using the WOW (work on wheels) that has a scanner. The pts have arm bands that scan. Some of the vials of medication don't scan well or have bar codes that don't read. Then we have to click on the med, bypassing the scanner. It is still a fallible system as it is possible to bypass it when one is in a hurry. I hope that this incident makes us all slow down and look at the labels. I know it has affected me.
  11. by   sddlnscp
    I am currently taking pharmacology calculations now (getting ready to finish up the class Tuesday, actually) and this story has really compounded all of the information that they are teaching us. It is so tragic, but it really underlines and puts exclamation points behind the fact that we must check dosages before administering meds!!! No matter how much of a hurry we are in or how wholeheartedly we trust our system, we still have to check, check and re-check because ultimately, we are responsible for making sure our patients get the correct dosage. I wonder about the students who complain about taking this class and how this should be "pharmacy's job" or "the doctor's job" when it is so obvious that human errors can occur and we have to know what we are doing in order to keep our patients safe! I feel so bad for all of the people involved in this tragedy. Hopefully many people will take away from this the importance of checking meds and calculating dosages before administering meds and hopefully because of that, those babies deaths will not be in vein.
  12. by   Quailfeathers
    I agree with Sarah; I'm a student as well and we're just starting meds. Reading and hearing the input from allnurses will certainly make me keep those 5 R's in focus! My prayers are with all the families involved.
  13. by   rita359
    So sorry to hear this happened. My first thought was how we learned about the five rights to drug administration. Don't know what system problems there might be but in the end, although this was heparin, it could be any med in any drawer in a pyxis system. A wake up call for all of us.