Error kills 2 infants in Indiana - page 5

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   rjflyn
    Reading the latest news article today it looks like the hospital is admitting it was a system error. Although the nurses, the patients last line of defense missed the ball as well.

  2. by   helpinghands
    Here is a quote from the latest article

    "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,"
  3. by   dawn1971
    I am a student and am currently doing my clinicals at Riley (Children's hospital that is part of Clarian, which is part of Methodist). RN's are now to double check heparin doses with another RN (this is a new policy) and are getting suprise visits from JHACCO... I think all of Clarian is trying to go to scanners and computer charting eventualy. Riley is to switch over at the end of the year. The whole thing just makes your heart hurt.
  4. by   MAP1
    This is definately a wake up call to all of us. i feel so badly for the people involved. No one went to work that day to try to harm someone. We all know how terrible we would feel given the same circumstances. I know when rushed or talking to patients it is hard to concentrate on administration of meds. We try to eliminate the hazards that can occur but mistakes do happen.
  5. by   indigo girl
  6. by   lee1
    Quote from 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.

    I just hope your nurse/pt ratios allow you the proper time to get your work done. I agree the 5 rights were violated and that people rush too much, BUT, why is that???
    Yes, this should make us ALL, take that extra time needed to validate.
    We now have to double validate (2 nursing signatures) at our hospital also, heparin, insulin (even subqu), dopamine,dobutamine.
  7. by   sirI
    Post #57 merged with existing thread.
  8. by   Cheyenne RN,BSHS
    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.

    [font="georgia"]i can imagine the sick feelings that these nurses must have at this time. my heart really goes out to them.

    we use meditech system where i work and it is set where you cannot bypass the system when something does not scan correctly. if the armband does not scan, as when it has been wet during a bath, then you have to stop and go to the nurses station and make a new one.

    if the drug does not scan, you have to call pharmacy and "mox" them to have the drug sent up with another label, or at times, the pharmacist has to re-enter the data. (mox is an internal email system in meditech))

    of course, errors or accuracy starts and depends upon the data/order being read and interpreted and then entered correctly.

    the 5 rights are forever paramount. i still look at every drug that i pull from the pixis (spelling??) system to make sure that what is stocked and what i withdraw are exactly what is ordered.
  9. by   CyndieRN2007
    Here is some video feed of the latest press conference with the parent of the 3rd baby that passed. It briefly shows the heparin vials. The pharmaceutical company states no amount of "Warning"labeling can replace to 5 rights that should be done by nurses.
  10. by   mareekha
    You have an excellent point. That is a big part of the problem. I have talked with the nurse manager and she said they are looking at decreasing their nurse/patient ratios. I believe she is sincere and really cares - but the system and the process and the availability of nurses are a hurdle she still has to cross. I am impressed with all of the responses and discussion that this incident has elicited. Say what they will, we nurses stick together and practice colleaguiality. GOD bless you all.
  11. by   mareekha
    Thank you for posting this, as I have not been able to follow this as I would like. It is really scary when you hear the mom blaming the nurses. I think they are punished enough with living with the knowledge of what they have done. It will be interesting to see what happens to them. I think it is encouraging that administration is standing behind them. Any other thoughts on what the mom said? I can't imagine how she must feel, as I have never had children of my own.
  12. by   CyndieRN2007
    I cannot fathom what the mothers are going through. I dont blame her for lashing out at the nurses. They were in fact, the ones responsible for administering the heparin, which they should have checked. Same color vial or not. My heart goes out to those nurses, they must be going through hell right now. I hope they recieve the counseling they need. This is just bad all the way around.
  13. by   INtoFL_RN
    This whole situation is so, so sad for everyone involved. Like many have pointed out, it is the fault of many, although the last line of defense should have been the nurses.

    I worked for Clarian (on an adult unit) a couple of years ago, and in our med room we had a list of "high-alert" medications. Heparin was on that list. Our particular unit had 5 different concentrations stocked in our Pyxis, so you better believe that I triple-checked everything! It's just so sad that so many steps were missed, especially in a NICU!

    This whole event must be hell for the entire Clarian system (and the families of the deceased babies). The one good thing to come out of this tragedy is the awareness for patient safety - not only in the eyes of the healthcare providers, but for the patients too.