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Corpus Christi Caller-Times/AP
Hector and Maggie Chapa, grandparents to twins Keith and Kaylynn Garcia, who died
this week at a Corpus Christi, Texas, hospital, talk about their grandchildren. (AP)
Hector and Maggie Chapa, grandparents to twins Keith and Kaylynn Garcia, who died
this week at a Corpus Christi, Texas, hospital, talk about their grandchildren. (AP)
Second Infant Dies After Heparin Overdose
July 11, 2008 05:46 PM
As many as 17 newborns in a Corpus Christi hospital have received overdoses of the blood-thinning drug Heparin, causing the death of premature twins.
30-Second Summary
Nurses intended to use the blood-thinner to flush IV tubes in order to prevent the formation of blood clots. But, hospital pharmacists made an error in mixing the Heparin solution, producing a dose over 100 times too strong.
Heparin is a widely used drug commonly used to flush IV tubes. Because it is so prevalent, it accounts for almost one-third of medication errors in hospitals. There have been approximately 250 medical errors involving children under 18 months.
Heparin overdoses killed three infants in 2006 and nearly killed the newborn twins of actor Dennis Quaid. The story received a great deal of media coverage and Quaid has since become an activist for the prevention of medication errors.
Heparin was recently the focus of a congressional hearing in an unrelated case. Supplies of the drug had become contaminated, leading to the deaths of many adult patients.
Producers of Heparin say the drug is safe, if used properly. All instances of infant overdoses were the result of errors by nurses and other hospital staff.
Hospitals are attempting to implement guidelines and electronic systems to prevent future medication errors. However, many experts believe that the only solution is for hospital workers to be more vigilant in administering medication.
Heparin is a widely used drug commonly used to flush IV tubes. Because it is so prevalent, it accounts for almost one-third of medication errors in hospitals. There have been approximately 250 medical errors involving children under 18 months.
Heparin overdoses killed three infants in 2006 and nearly killed the newborn twins of actor Dennis Quaid. The story received a great deal of media coverage and Quaid has since become an activist for the prevention of medication errors.
Heparin was recently the focus of a congressional hearing in an unrelated case. Supplies of the drug had become contaminated, leading to the deaths of many adult patients.
Producers of Heparin say the drug is safe, if used properly. All instances of infant overdoses were the result of errors by nurses and other hospital staff.
Hospitals are attempting to implement guidelines and electronic systems to prevent future medication errors. However, many experts believe that the only solution is for hospital workers to be more vigilant in administering medication.
Headline Link: Twins die of Heparin overdose
The twins were born a month prematurely at Christus Spohn Hospital South in Corpus Christi, Texas. On July 4, they were two of 17 premature infants given large doses of a Heparin solution that had been improperly mixed and labeled. The mistake was recognized two days later and nurses gave the infants medication to counteract the Heparin. The twins died on July 8 and 9, but the other infants are expected to survive. Two members of the hospital pharmacy staff have taken a voluntary leave while the hospital investigates.
Source: CBS News
Background: Dangers of Heparin
In 2006, an Indianapolis hospital administered doses of Heparin solution 1,000 times stronger than intended to premature babies, killing three. The error occurred when a pharmacist technician mistakenly stocked a medicine cabinet with vials of the stronger dose. Nurses used these vials even though they were labeled and color-coded as the stronger dose.
Source: Washington Post
In November 2007, the newborn twins of actor Dennis Quaid were administered doses 1,000 times too strong. It was caused by three separate employees failing to verify its contents, a violation of hospital policy. The infants survived, but the family sued and started the Quaid Foundation to improve hospital safety.
Source: Los Angeles Times
In April, Robert Parkinson, CEO of Heparin producer Baxter, was called before Congress to speak about contaminated shipments of Heparin that killed 81 people in 16 months. He said that Chinese suppliers had contaminated the drug as part of a “deliberate adulteration scheme.”
Source: findingDulcinea
Opinion & Analysis: How can these errors be prevented?
The Wall Street Journal’s Theo Francis addresses how technology can help prevent future medication errors. He points out that computer physician order entry, which allows doctors to order medication electronically rather than in handwritten notes, would not have prevented the errors in Corpus Christi, Indianapolis or Los Angeles. Bar Code Medication Administration, which puts bar codes on medication that can be scanned on a patient’s armband, would not have helped the Corpus Christi infants. It that case, the order was incorrectly filled and labeled, so the barcodes would not have caught the mistake. Francis believes that technology is not a cure-all and the only way for hospital workers to minimize mistakes is to be more vigilant.
Source: Wall Street Journal
The Institute for Safe Medication Practices examined the issue after news of the Quaid infants broke. It placed blame on a lack of attention to safety and poor “learning culture.” It wrote, “workers must possess the willingness and competence to draw responsible conclusions from robust internal and external safety information systems and make substantial changes when necessary. Too often, practitioners read published reports about harmful errors but do not truly believe the events could happen to them. Absent shared learning, the same heparin error will likely occur in other hospitals.”
Source: Institute for Safe Medication Practices
© 2009 Dulcinea Media, Inc.
