Posted on 07/09/2008 11:05:15 AM PDT by SwinneySwitch
Infant seriously ill before blood thinner error
One newborn is dead after a Christus Spohn Hospital South pharmacy error that led to as many as 17 babies getting as much as 100 times the recommended dosage of the blood thinner heparin.
It's still unclear what role, if any, the heparin played in the infant's death, because the child already was seriously ill and being cared for in the neonatal intensive care unit before dying Tuesday morning, said Dr. Richard Davis, chief medical officer for Christus Spohn Health System.
Heparin routinely is used in the hospital's neonatal intensive care unit to flush intravenous lines and prevent blood clots from forming. The dosing error was discovered by nurses Sunday night, during routine blood work, hospital spokeswoman Sherri Carr-Deer said.
"With babies, that is usually a heel stick and the nurses noticed that the blood was not clotting," Carr-Deer said.
They discontinued the drug's use immediately and gave newborns who needed it medications to counter its effects.
One infant remains in critical condition in the unit, and was in that condition for several days before the heparin dosages, Davis said. Three infants have been discharged and 12 are stable and remain in intensive care. Officials said an autopsy on the deceased infant will be conducted but did not say when that would occur.
A preliminary investigation indicates that the error happened during a process Thursday in which pharmacy personnel mixed the heparin with other solutions, including saline.
There was a double-verification process in place in which the pharmacy technician prepared the medication and the pharmacist signed off on it.
The heparin first was administered in the neonatal intensive care unit Friday. It's unclear how many of the children were dosed, because there were syringes from a different drug batch in medical cabinets in the unit, Davis said.
"Our pharmacies have very specific processes to follow in the preparation of medications," said Bruce Holstien, president and CEO of Christus Spohn Health System. "Obviously in this case something went terribly wrong."
The hospital's immediate actions included a review of policies and procedures with pharmacy staff and the implementation of a third layer in the drug verification process, meant as a stopgap measure to prevent similar incidents, Holstien said.
Two members of the hospital's pharmacy staff have taken voluntary leave, pending an investigation that could take as long as two weeks, Holstien said, adding state and federal agencies including the Texas Department of Health Services and the U.S. Food and Drug Administration have been notified.
Emily Palmer, a spokeswoman with the Texas Department of Health Services, said the agency is aware of the situation, but said she could not disclose whether there is a complaint or investigation because of confidentiality rules.
"We license hospitals and within that licensing there are a number of things we can do," she said. "We can make visits, we can make recommendations, we can make requirements and there can be penalties. This is speaking in general about hospital licensing."
The incidents also have been reported to the Joint Commission on Accreditation of Healthcare Organizations, an independent, nonprofit agency that accredits and certifies more than 15,000 hospitals in the U.S. including those in the Spohn system, Holstien said.
During the past 18 months, there have been roughly 250 medical errors nationwide involving heparin and children a year or younger, according to U.S. Pharmacopeia, the public standards-setting authority for all prescription and over-the-counter medicines, dietary supplements and other health-care products manufactured and sold in the United States.
In September 2006, three infants died in an Indianapolis neonatal intensive care unit after receiving a 1,000-fold overdose of heparin. And in November 2007, the infant twins of actor Dennis Quaid and his wife, Kimberly, were the victims of a nearly identical mistake, an overdose of heparin at Los Angeles' Cedars-Sinai Medical Center, where the pharmacy dispensed the wrong dose to the nursing station, according to reports from the Associated Press.
In December 2007, Baxter Healthcare Corp., the drug's maker, introduced a new drug safety initiative that includes labeling with a 20 percent larger font size, a different color combination, and a red cautionary tear-off label.
On vials of the drugs meant for adults, the label now warns that it should not be given to infants.
Davis said labeling likely had nothing to do with the Spohn incident because the pharmacy mixed the drug batch itself.
Contact Jaime Powell at 886-3716 or powellj@caller.com
Prayer ping!
If you want on, or off this S. Texas/Mexico ping list, please FReepMail me.
7000 deaths per year due to medical errors in hospitals
20,000 deaths per year due to other errors in hospitals
(source: JAMA July 27, 2000) 80,000 deaths per year due to infections from hospitals
106,000 deaths per year due to negative effects of drugs
Moral to story: Don't go to hospitals or pharmacies unless absolutely necessary.
Someone in the IV Room screwed up big-time. And the pharacist(s) who checked his/her work screwed up big-time.
Heparin is on a short hit-list of the most important medications to watch when infants are involved.
There are times when a large bag is used to make up a heparin supply to be used on infants for a 24 hour period. If this bag is made improperly, and the pharmacist doesn’t catch it, the damage can be spread across a number of infants.
That may be what happened here.
You hate to see things like this take place, but humans being what they are, this is bound to happen from time to time.
Joint Commission and other inspection teams can help pharmacies to institute programs to avoid these types of situations, but they will still happen, sorry to say.
I don’t entirely disagree with that, but people do need medical care and they shouldn’t put it off. Those numbers you posted sound huge. When you think of the total hospital population base, they aren’t.
One average size hospital can have upwards of 100,000 to 150,000 patient days per year. Even in an area like Los Angeles, you probably have something on the order of 15 to 25 million patient days per year. And when you extrapolate that out to nationwide, we’re talking about many millions or perhaps even a few billion patient days per year.
If you looked at the statistics for death from auto accidents or even the injuries as a result of auto accidents, you’d be tempted to avoid ever being on one of our nation’s highways or roads.
Pharmaceuticals if used reasonably, and hospital care if used prudently is a wise move.
Sounds worse than our war losses in Iraq. Shock, shock, calling Nancy Pelosi, Harry Reid, Barbara Boxer; let them put their energies into this mess.
and they say that guns are dangerous!
Considering the amount of money doctors, nurses and pharmasists are paid, those number ARE huge.
But you’re right, people should seek out medical advice and care when needed.
Too much heparin and you will bleed everywhere including the brain. Major emergency.
I’m afraid they’d make matters worse. Probably will with their Universal HealthCare.
True enough... I know what you mean.
There are so many ways to respond that I could spend quite a bit of time on this point.
Some folks thought it was an unfair complaint that hospitals were put under stress due to illegal aliens who were unable to pay for their healthcare. Well okay, that’s a point of view that is out there.
I have spent years trying to explain to people that when money becomes tight, it causes pressure on things that would seem totally unrelated to services provided to illegal immigrants.
Which equipment will be purchased and used? How many staff members will be alloted to this task? How often will the halls be moped, striped, waxed and buffed? How clean will the place be overall? How many days will your wife spend in the hospital after giving birth? What will the patient stays be across the board?
These decisions and many more are all impacted by the financial health of hosptials. And our hospitals have been under attack across the board for twenty years. I tried to sound the alarm. As often as not, I was riduculed for doing it. Oh I was a nervous nellie, or I was just a racist ass trying to blame everything on illegals.
Look, what hip your are going to get, is dictated by the hospitals need to remain solvent. What cateract lense you get hinges on the hospitals need to remain solvent. What type of therapy you get is contingent on the hospitals need to remain solvent. Someone doesn’t pay, and we all pay for it.
This may seem like a long way around the bush to get where I am headed here, but folks need to know.
Those physicians, nurses, pharacists and technicians are all affected by the hospital’s ability to remain solvent.
In this environment, the shifts of I.V. Technicians are cut back. The number of them on duty at one time is cut back. The number of pharmacists who are going to check their work is but back.
And then you have the state swooping in to tell pharmacists that they are going to have to implement this new regulation, which will require much more of their time. And their ability to function at the level they need to is impacted negatively again. And then you have the state demand that the pharamcy run around to every unit in the hospital monthly to check medication outdates. And the ability of pharmacy staff to spend time on their first calling, is reduced even further.
It’s amazing to me that more errors don’t take place.
Nurses are asked to cover more patients all the time. They are asked to do more documentation. They along with everyone else are required to jump through hoops so that patient information is protected.
This all adds to a working environment where everyone is pushed to the breaking point. And if you figure in pharmacies that take care of long term extended care facility patients, you’ve often got corporate pressures that are impossible to cope with.
The pay has nothing to do with it, I can guarantee you.
7000 deaths per year due to medical errors in hospitals
20,000 deaths per year due to other errors in hospitals
(source: JAMA July 27, 2000) 80,000 deaths per year due to infections from hospitals
106,000 deaths per year due to negative effects of drugs
Per year, folks. Year after year. Decade after decade.
The above adds up to 225,000 - on the Journal of American Medical Assoc. Other reports put the number closer to 300,000
Where is the media's drumbeat on all these deaths?
What? No political gain?
Oh, never mind then.
In the meantime, do all you can to keep yourself and others healthy. If you must have an operation, print directions on yourself as to what operation and where you are supposed to have...NOT a joke. (Wish I had done it. I will if ever needed again.)
I might of been a little hard on the industry but, IMO, the higher the pay, the higher the accountability.
Who makes the most money? Physicians. They generally don’t administer mediations. I don’t mind your assumptions, because I don’t necessarily disagree. Unfortunately, it’s not that easy to pin down.
Take care WolfCreek.
Dreadful. RIP.
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