Heparin Errors in the NICU

2006 Words5 Pages

Statistics show that between 1979 and 2006, there were more than sixty two million deaths investigated and of those, 244,388 were caused by a hospital medication error (Cox, 2010). The following information highlights medication errors made in three facilities in the United States with the drug Heparin. The focus of this paper will be on how the medication errors were made, what could have prevented them, the legal ramifications from the mistakes, and changes that were implemented to eliminate potential future risks. In September 2006, at Clarian’s Methodist Hospital in Indianapolis, six infants in the Neonatal Intensive Care Unit (NICU) were accidentally given excessive doses of heparin, resulting in the death of three of the infants (Thew, 2006). This day started out just like any other day in the newborn intensive care unit at Methodist. The nurse went to the medication cabinet to dispense Heparin, a blood thinner, for a handful of premature babies. This was a normal routine for the nurses in the NICU. Reports indicated that a pharmacy technician stocked the wrong vial dose of heparin in the NICU medication storage cabinet. The correct dosage of heparin for the use in flushing intravenous catheters is 10 units per mL, but unfortunately the technician stocked the 10,000 units per mL vials. Both vials are quite small and resemble a similar color of blue (Simpson, 2008, p. 135). The heparin vials responsible for the tragic events at Methodist Hospital were manufactured by Baxter Healthcare Corporation. In February 2007, Baxter “issued an Important Medication Safety Alert warning to healthcare providers that the look-alike features of the two vials with vastly different doses presented a risk of life threatening medication errors... ... middle of paper ... ... over babies’ hospital drug mishap. (2009, June 19). KTLA. Retrieved from http://www.ktla.com Simpson, K. R. (2008, March/April). Perinatal patient safety: Medication safety with heparin. The American Journal of Maternal Child Nursing, 33(2), 135. Retrieved from http://www.nursingcenter.com Thew, J. (2006, December 11). All things considered – Clarian examines its healthcare delivery system. Retrieved July 24, 2011, from http://nurse.com Vonfremd, M., & Ibanga, I. (2008, July 10). Officials investigate infants’ heparin OD at Texas hospital. ABC News. Retrieved from http://abcnews.go.com Waknine, Y. (2007, February 9). Heparin product similarities linked to fatal medication errors. Medscape News. Retrieved from http://www.medscape.com We’ll sue. (2008, March/April). Neonatal Intensive Care, 21(2), 10. Retrieved from http://www.nicmag.ca/pdf/NIC-21-2-MA08-web.pdf

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