Hospital error blamed for more infant overdoses

[flashl]

CORPUS CHRISTI, Texas - The case of 14 babies who received accidental overdoses while in intensive care has raised new questions about how a common blood-thinning medication could be given to infants repeatedly in the wrong dosage.

Unlike a previous case involving twins of actor Dennis Quaid, the Texas newborns got the overdose because of an error at the hospital pharmacy, not a labeling problem.

Quaid sued one of heparin's manufacturers last year after his children's overdose was traced to a hospital pharmacy worker who grabbed vials of the wrong dosage because the labels looked almost identical if turned a certain way.

...

The heparin, which was 100 times stronger than recommended, was given to 14 infants in the hospital's neonatal intensive care unit on July 4.

Yahoo

[Warpy]

1. That labeling drove me nuts for years

especially because short staffing means not having the time to read everything carefully enough. If the pharmy grabbed the wrong thing and the labels are the same, then an accident will happen eventually, especially when an exhausted nurse floated from a unit that doesn't use that drug might not know of the labeling problem. Add to that the fact that the labels are small ones on small vials with minute writing.

There is an antidote for heparin if the mistake is discovered in time.

The fix for the manufacturer is a cheap one: just change the color of the plastic cap on the vial so that the two doses are colored differently.

Now that the double tragedy of twin babies dead from an overdose has occurred, maybe they'll do something about it. My complaints over more than a decade did no good.

[beam me up scottie]

2. Are you saying that they knew about this years ago and never fixed it?

Somebody's kids are dead because they were too cheap to change the colour of a cap.
How many others have died because of this?

They shouldn't just be sued, they should be investigated and punished.

[Warpy]

3. They don't fix anything until the FDA makes them

and the FDA doesn't bother with anything that doesn't produce a cluster of deaths.

After all, when they can blame the nurse who administered the drug, which is what they do and probably what will happen in this case, why bother?

Vial labeling is especially problematic. One drug we gave IV for years had what looked like a smudgy line on the bottom of the identification printing. We put it under a microscope to determine that the run together ink was actually "for IM use only."

Luckily, the guidelines had been changed even though the obsolete labeling hadn't.

[beam me up scottie]

5. The company that the Quaids are suing blamed the nurses and the pharmacy.

They knew this happened many times before, only fixed the problem after the celebrity parents sued and didn't bother to recall the existing stock.

[flashl]

4. Dennis Quaid is suing

Baxter’s Other Heparin Problem: Dennis Quaid

March 2008

Baxter’s problems with the blood thinner heparin aren’t limited to contamination and a recall.

The company’s also facing a lawsuit and some terrible publicity from Dennis Quaid, who’s going on 60 Minutes this weekend to talk about hospital errors, Baxter’s heparin and the near-death experience of his newborn twins.

Last year, before the contamination problems emerged, a nurse at Cedars-Sinai Medical Center in Los Angeles was supposed to give the movie star’s babies a dose of Baxter’s Hep-Lock, a weak form of heparin to keep IV lines open. Instead, the nurse gave the babies full-on heparin, causing a drug overdose that could have been fatal. “Our kids are bleeding from everyplace that they’ve punctured,” he recalls in the interview. “It was blood everywhere.”

The twins recovered. But Quaid’s taken up the cause of reducing hospital errors, and he’s suing Baxter.

WSJ

[beam me up scottie]

6. Thanks, I just now looked at the details of their case.

If he wasn't famous nothing at all would have been done to correct this.