Autopsy Planned For Newborn Given Heparin

An Overdose Of Blood Thinner May Have Killed Preemie In Texas

(CBS/AP)  An autopsy on a newborn is planned to determine whether an overdose of the blood thinner heparin may have been a factor in the baby's death, officials at a Corpus Christi hospital said.

Two members of the Christus Spohn Hospital South's pharmacy staff have taken voluntary leave, pending an investigation that could take as long as two weeks, said Bruce Holstien, hospital president and CEO, in Wednesday's edition of the Corpus Christi Caller-Times. He said state and federal agencies including the Texas Department of Health Services and the U.S. Food and Drug Administration have been notified.

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, the hospital's chief medical officer.

Officials did not say when the autopsy on the deceased infant would be conducted.

The infant was among at least 17 babies given an overdose of the pediatric version of heparin. Heparin routinely is used in the hospital's neonatal intensive care unit to flush intravenous lines and prevent blood clots from forming.

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.

A preliminary investigation of the incident in Corpus Christi indicates that the error happened during a process Thursday in which pharmacy personnel mixed it with other solutions, including saline.

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.

The dosing error was discovered by nurses Sunday night, during routine blood work, Christus Spohn Health System spokeswoman Sherri 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.

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.

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, was notified, officials 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.

Don''t work part time nurses for 50 or 60 hours a week so you can pay them part time wages and withhold full time benefits. This is a field that is not only exhausting physically but mentally as well.

Medicine is a field that is dominated by humans. Humans are not machines and there will be errors. However, this type of error can easily be corrected with proper dosing mechanisms as well as staffing shortages.

It is sad that it took a celebrity to bring this to light. If it were you or me, I would only hope that the publicity would be half as good.

[barbaraf4]

When I had back surgery and knew I was going to be out of it on pain meds for several days, I asked my husband to be my advocate. During the 7 days I was in the hospital he had two responsibilities: make sure everyone who touched me had washed their hands and check every med brought into my room that would be injected into my IVs.

[jdubs63]

Veilwanger.. well said thank you. In my 30 years of nursing I have never made a medication error.

[ajaxrose1]

What''s really bad is this has been going on for a very long time, but until it affects a famous person and they jump on a crusading band-wagon, no one pays any attention to it. (It''s always interesting to me that most celebrities only take up the mantle of whatever the latest cause is when they''ve been affected somehow.) If labeling is a problem then fix it. If inattention is a problem then maybe try working nurses for 6 or 8 hour shifts instead 12 or 16, so their minds stay sharper; a smaller patient to nurse ratio would be a good idea, too. PS to newster1: take a chill pill you jerk. It''s not okay with anyone when a baby dies, no matter what the reason.

[danwalter2]

Even "America''s Best Hospital" makes mistakes:
Google "Adventures in Cardiology"

[danwalter2]

This kind of thing goes on everywhere - even at "Americas'' Best Hospital"

Google "Adventures in Cardiology"

[sociald63]

i will remember your family in my prayers

[vellwanger]

There are certain procedures that a person that is administrating medication to anyone is suppose to follow. There are five rights that are to be read on each label, two of those rights are right medication and right dose--these rights are read two times before administrating them and once after. It''s due to human error that people are being given wrong medication. If you have been doing too many hours and are tired, too tired that you can''t understand what you are given, I suggest you let your supervisor know and hand over the med keys to someone capable of administrating the right dose and medication to the right person at the right time, and the right route. I wouldn''t want someone''s life lost due to my error. Use commomn sense.....

[imicurn-2009]

Yes, there is a shortage of nurses, I have been in practice for 26 years and I find that with the complex techniology that we deal with, incoming nurses are not getting the length of precepting and the doctors, especially in teaching facilities are not prepared for their level of responsibility. I feel that when nursing schools were based in hospital programs and orientation was freely given it was different. I also believe that the lack of well trained personnel in all departments is a factor that figures into medical error. My heart goes out to all that have suffered from medical mistakes. Labelling and proper stocking and keeping hep-lock and Heparin seperated is a consideration and pharmacy labelling clearly is also and issue. A staffing shortage is NO EXCUSE for medical error!!!

[psk123-2009]

Many of the mistakes made in hospitals is from the fact that there are too few nurses on staff. (the administration must have those big pay checks, who can afford enough nurses to go around too!) Many mistakes are made because too many doctors can not write in a fashion that is readable. Many mistakes are just plain carelessness. Most mistakes are avoidable.

[nothappyatall]

he child already was seriously ill and being cared for in the neonatal intensive care unit before dying "

Oh well, have another one, better yet do your part to save the planet and environment and DONT! till there are NONE in foster care ADOPT ONE, don''t breed!

[Gary Kempf]

Stricter standards need to be applied in either labeling or administering the the heparin. this is ridiculous...

[arnldmartin]

Hospitals make LOTS of mistakes,I almost lost my leg because of one.