14 Preemies Given Blood Thinner Overdose

Babies At Texas Hospital Given Too Much Heparin; Mistake Probed, Children Being Monitored

(CBS/AP)  A Corpus Christi hospital says 14 babies in its neonatal intensive care unit received overdoses of the pediatric version of the blood thinner Heparin.

Christus Spohn Hospital South CEO Bruce Holstein says the error in the dosage of the medicine - used to flush intravenous lines to prevent blood clots from forming - was discovered Sunday night by hospital nurses. He says the nurses noticed abnormalities in lab tests.

The Corpus Christi Caller-Times reports the hospital discontinued using Heparin immediately and gave newborns who needed it different medications.

It was unclear how much over the recommended dose was given to the 14 patients. Holstein says there's a standard dose for newborns.

Pharmacy operations were halted temporarily Monday. He said the error was believed to have happened in the pharmacy when the medicine was mixed.

Officials said two babies have been released since the discovery was made and the others are being monitored carefully. Holstein said the babies' reactions to the overdoses varied, and he did not know details about effects.

Holstein said hospital staff would report the incident to the Joint Commission on Accreditation of Healthcare Organizations, an independent, nonprofit agency that accredits and certifies more than 15,000 hospitals in the United States.

In November 2007, actor Dennis Quaid's newborn twins were at the center of a near-fatal drug mix-up in which they were administered 1,000 times the normal dose of Heparin.

"We all have this inherent thing that we trust doctors and nurses, that they know what they're doing. But this mistake occurred right under our noses, that the nurse didn't bother to look at the dosage on the bottle," Quaid told 60 Minutes correspondent Steve Kroft in a March interview. "It was 10 units that our kids are supposed to get. They got 10,000. And what it did is, it basically turned their blood to the consistency of water, where they had a complete inability to clot. And they were basically bleeding out at that point."

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Read The 60 Minutes Interview With Dennis And Kimberly Quaid

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Quaid's children recovered, and he has since testified before Congress in an effort to draw attention to what is one of the leading causes of death in America - preventable human, medical error.

"These mistakes that occurred to us are not unique," he told Kroft.They happen in every hospital, in every state in this country. And 100,000 people, that I've come to find out, there's 100,000 people a year are killed every year in hospitals by a medical mistakes."

The same avoidable mistake had occurred a year earlier at Methodist Hospital in Indianapolis. Six infants were given multiple adult doses of Heparin instead of the pediatric version; three of the infants survived, three did not.

[worriedmom1]

I understand that accidents happen and such. However, this hospital is notoriously known for other mishappenings.
For some reason they are big on inducing births and using the "yoru baby is going to be big" excuse on mothers. I now this because I was one of those mothers. My baby was delivered almost 5 weeks early and was only 5lbs 7oz. My poor child has suffered from delayed speech to a current diagnoses of autism, add, and we are still doing more tests to see what is wrong. I know I am not the only one because other mothers have spoken about what they have gone through as well. Each were told that their baby was going to be too big to deliver and were induced early only to have low birthweight babies.
A man came in for surgery for something minor and came out handicapped for the rest of his life. Teh hospital knew they did wrong but did not admit to it and just did not send the patient his bill. If you go to the caller.com website you will see all of the stories on there from others that were wronged by this hospital. It goes further beyond individuals not double checking their work. This hospital is privately owned and will do whateve it takes to cover up mistakes. Unfortunately, they could not cover up something this big. One baby has already died. Newborn moms are wanting out of the hospitals immediately.

[erasmus81]

toldyouso12

I can see you are still out of control with your posts.

[erasmus81]

"Yep--when the Government runs things they are SOOOOO much better (Not)"Posted by toldyouso12 at 12:34 AM : Jul 09, 2008

Yes, in my country it IS sooooooo much better. In yours, NOTHING that is run by the government is better.

[toldyouso12]

The government should mandate that pharmacies and meds for infants and children below a certain body weight, should be stored, mixed and dispensed from a separate site than the regular pharmacy. Take one of those double rooms and turn it into a pharmacy for the infants and children--then rewrite all SOPs to mandate all supplies for kids go to that area. The nurses would have meds for their patients on hand, the chances of a mix up would be very small (if the staff would still check and confirm the correctness of the inventory when stored and prior to compounding)

[toldyouso12]

To those posters that hate on the medical profession and personnel...yes, there are those of us that are callous. But the overwhelming majority of us care very much for our patients, and would be devastated if our actions injured any one of them.

Posted by aaronh888 at 12:44 AM : Jul 09, 2008


Your post reminds me of a coworker who once dismissed the amount of death and infection due to our products (I worked in Pharm and Biologics) by stating that 80K/year was not that great a number when you considered how many people we served each year. I submit to YOU and to that colleague that even 1 death is 100% devastating if YOU or your loved one is that patient.

Some errors are understandable, some are frankly--unforgiveable. There are safeguards that should be put into place that could avoid stuff like this--how about an adjunct pharmacy for children and infants located directly in that ward? All meds for children and infants only would go through there and all staff would be specifically trained to handle only infant and child dosages. Because the meds would be segregated, there would be less chance of mix up--because there is always the possibility, that this was not a simple error, but a malicious act of a very sick person. After all, the nurses had no idea what potency pre-mixed medicines were--but whoever mixed it up, should have known, checked and rechecked their work. This could have been avoided--you can always tell the patient that the cost was passed on to us, anyway.

[toldyouso12]

I just re-read this article. It turns out the culprit is not the nursing staff, but the pharmacy staff. There is no way for the nursing staff to know the potency of a product that is delivered in a syringe or already premixed with a diluent. NO WAY. Only the Pharm staff knows what they did, and why--heads should roll,.

There are a lot of incompetent people out there. When a loved one in my family was taking a very strong diuretic and was in need of potassium to stop muscle cramps and worse, she had to wait over 4 hours, moaning in pain, before the nurse who checked her chart noted that the Potassium drip had not been administered. Why? The pharm staff had never showed up to give it, but someone had marked it as given in the chart--this was found out by my sister who was an RN. She then called the charge nurse who checked with the pharmacy and found out that the meds had never left their area. My mom could have died. There needs to not only be scrutiny of drs and nurses but of pharm techs and pharmacists--this is an area that for too long has been overlooked as the culprit to much negligence. What ever I wrote about the nurses--we can apply to the pharmacy workers.

[aaronh888]

100,000 sounds like a large number. It is. However, keep in mind that there were 37,188,775 hospital admissions in 2006 in the United States. Hospital staff aren''t looking to make mistakes. In fact, they are always trying to minimize errors. As was pointed out by a few posters above, it is very transparent and tragic when mistakes are made in the hospital. However, there is no other place than a hospital that is more vigilant in actively trying to minimize errors. Hospital workers know the stakes, and that they are very high. We know that human life is at stake. Measures, both retroactive and proactive, are implemented, and procedures are continuously reviewed and refined, to ensure patient safety as much as possible.

To those posters that hate on the medical profession and personnel...yes, there are those of us that are callous. But the overwhelming majority of us care very much for our patients, and would be devastated if our actions injured any one of them.

[toldyouso12]

his drug has similar labels for different doses. The difference is a decimal point.

Posted by impeach__w at 03:32 PM : Jul 08, 2008


Then find a different supplier. Baxter is not the only one to manufacture Heparin. It is a generic drug--find a supplier where the color coding and info is more user friendly--or shut up and take the lumps for making the mistake. It is not as if this has not already happened in the recent past or as if the hospitals are just now discovering similarities in the labeling.

[toldyouso12]

his drug has similar labels for different doses. The difference is a decimal point.

Posted by impeach__w at 03:32 PM : Jul 08, 2008


WRONG.The difference is more than that. Different color caps for different potencies and the difference is usually also mg/ml versus g/ml, most infant meds are also marked --for INFANTS or Neonatal or Adult or Child. THAT is also usually part of the labeling.

[toldyouso12]

Not saying it''''s an excuse, every dose should be read by two different people and there should be no mistakes. All I''''m saying is legalese on labels does not help their clarity.

Posted by NewTagAgain at 02:40 PM : Jul 08, 2008


The FDA reg. for labels are there, due to mix ups--but all the potency of a product always appears right under the name of the med which is right under the NDC number. And the bottles for each type of potency from each company is color coded. This was inattention due to overworked and foreign staff, who cannot be counted upon to always be able to decipher, understand or perform nursing functions by rote--as they often are operating on little sleep and in another language.