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.

[toldyouso12]

Accidents can happen anywhere, but these are the kinds of things that you will see happen when a hospital is privately owned. The quality of care, cleanliness, all go downhill. They aren''''t accountable to anyone. The people no longer have control over how it is run.

Posted by erasmus81 at 01:17 PM : Jul 08, 2008


Yep--we all thought the EXACT same thing, when we saw the pics of Walter Reed with the cockroaches running everywhere, and soldiers waiting 2 years for brain trauma injury---then we saw how well the Government was running things at Ft Bragg, where the injured had to help plunge the bathroom toilets because they had **** and feces all over the floor...

Yep--when the Government runs things they are SOOOOO much better (Not) then there was that state run psych hospital where patients wait in admittance for over 24 hours and a woman just dropped dead the other day--and everyone ignored her on camera. Yep--when the government is in charge--you just have less people you can actually hold accountable--but the horrors are still there.

[toldyouso12]

If you''''re in the medical profession you better get your act together...If 100,000 Americans died riding the bus or on school playgrounds there would be an outcry like none heard before...Mistakes should NOT be happening in hospitals...You''''re supposed to be professionals...ACT LIKE IT!

Posted by cantshutup at 10:32 PM : Jul 08, 2008


It''s true--100K per year and rising--but this has been going on for years and we put up with it--not just due to negligence, also due to poor hygiene on the part of the hospital (many end up with bacterial infections or contamination due to nurses not washing properly between patients) But why should hospitals and doctors and nurses change? When my child was in the hosp with pneumonia, one day she went to the play room, another child was playing with stuffed animals. That child had a staph infection. I forced them to close down and disinfect that play room and get rid of any toy that cannot be disinfected. That was not a popular decision.

Drs are the only people who can botch the job, kill their client and still get paid for it.

[toldyouso12]

Too many meds? Too many poorly educated in key roles at hospitals? Too many lazy staff who can''''t be bothered with taking the time to read the labels?

Posted by Credibility2 at 01:06 PM : Jul 08, 2008


The majority of nurses now, are foreigners--perhaps after being overworked and understaffed and having been visa-d in at lower pay--these nurses often get confused in reading English. After all, Foreign nurses are hired while nursing students in America are forced to take irrelevant but really hard classes and have their entry rate limited to about 16 students per year per college.

We had less of this in the past, because mostly American nurses who could read and understand English as a first language, were in charge.

[toldyouso12]

There seems to be a lot of problems with nurses and preemies in Texas. What was it? A few months ago, 8 were killed when given Heparin? Then there was that case of giving some Adult insulin by mistake..now this. Preemies are called the "million dollar babies" because a lot of them require so much care, their bills approach this.

With a large population of indigent people in TX and many teens having a lot of these preemies--here is an ominous thought: that because many of the babies will never have their bills paid by the parents but hospitals cannot deny these cases--could people subconsciously be trying to lighten their financial burden by getting rid of some of these babies?

There are all kinds of ways to prevent mix ups like this--from having each med scanned and lock out preventing certain potencies to even be on certain wards, to having more than one nurse check critical meds.

Medicines by law must have different codings for different levels of potency. This means if a med comes in potencies for babies and adults the color caps or pills will be a different color and shape--on top of that, the bar code on the bottles should sound an alarm if dosages are used in neonatal, that should not be there. It is a simple matter to have handheld scanners to verify the info on the bottles or to alarm if they are incorrect--that would at least alert the staff to check the potency and not allow them to enter that info.

[eloso]

It is not just newborns. I was on a heparin drip 24/7 and the pharmacy clearly had not mixed the correct concentration. I knew something was wrong when my urine looked like blood.

[cantshutup]

Also, St. Johns Springfield Missouri...took my mom in for surgery...went to check her into her room...the whole hall and the room smelled like pi ss...i went to a nurse and quietly mentioned it, she looked at me like she could slap me..."OK" she said. I said, "This is a hospital, it should at least SMELL clean." no response, went to my mother''s room and heard some nurses in the hall, "It DOES smell in here"...they brought a cotton ball dipped in peppermint to mask the odor rather than have housekeeping clean up the source which i found in the waiting room across the hall...a pi ss soaked chair. nice

[cantshutup]

"Let''s all remember that we are all human. I know that this is a terrible mistake but we all make them. Just some of us don''t have so much liability in our mistakes.Let''s all pray that this doesn''t end tragically for any of them."Posted by american30

100,000 AMERICANS DIE A YEAR...*DIE*...FROM MISTAKES BY THE MEDICAL COMMUNITY...100,000 DEAD because of "mistakes"......UNACCEPTABLE!!!!!!!!!!!!!

If you''re in the medical profession you better get your act together...If 100,000 Americans died riding the bus or on school playgrounds there would be an outcry like none heard before...Mistakes should NOT be happening in hospitals...You''re supposed to be professionals...ACT LIKE IT!

[stn_sage]

As I read this article I felt my pulse quicken, the blood drain from my face, and my jaw drop in disbelief and total disgust! I can only say this:

First, while acknowledging that it is tough to operate near error-free, that must be the objective! This---it seems to me---was the type of mistake that should NOT have been made!

Second, those responsible need a reorientation lecture on job procedures and safety---presented in a positive manner and not derogatorily!

Third, this hospital should be placed on type of ninety-day ''watch list'' by the state to see that they maintain safety standards.

Finally, the families of these babies, and all patients entering this hospital have to confidently know that they''ll leave the hospital healthier than they were when they came in! It''s the job of hospital staff and employees to see that this happens!

[stn_sage]

As I read this article I felt my pulse quicken, the blood drain from my face, and my jaw drop in disbelief and total disgust! I can only say this:

First, while acknowledging that it is tough to operate near error-free, that must be the objective! This---it seems to me---was the type of mistake that should NOT have been made!

Second, those responsible need a reorientation lecture on job procedures and safety---presented in a positive manner and not derogatorily!

Third, this hospital should be placed on type of ninety-day ''watch list'' by the state to see that they maintain safety standards.

Finally, the families of these babies, and all patients entering this hospital have to confidently know that they''ll leave the hospital healthier than they were when they came in! It''s the job of hospital staff and employees to see that this happens!

[christitty]

"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.



...understand that these errors happen and people genuinely take action to try to prevent them. It''''s not easy.
Posted by wheilala

Like I said, arrogant, uncaring...