2 infants die after getting adult doses of drug

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INDIANAPOLIS (AP) -- Two premature infants died after receiving adult doses of a blood thinner, a hospital said Sunday, blaming the incident on human error.

Four other infants in the Newborn Intensive Care Unit of Methodist Hospital also received adult doses of Heparin, and one might need surgery, said Sam Odle, chief executive of Methodist and Indiana University Hospitals. The other three were in serious condition.

Two babies born at 25 and 26 weeks' gestation died Saturday night, Odle said. Both were born in the last week, officials said. A full-term pregnancy lasts 38 to 42 weeks.

"These are very, very small babies," Odle said. "We are confident that no other infants except for the six were affected."

Heparin is routinely used in premature infants to prevent blood clots that could clog intravenous drug tubes, said Dr. James Lemons, a neonatologist at Riley Hospital for Children.

An overdose could cause severe internal bleeding, he said.

dark_shadows said:

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INDIANAPOLIS (AP) -- Two premature infants died after receiving adult doses of a blood thinner, a hospital said Sunday, blaming the incident on human error.

Four other infants in the Newborn Intensive Care Unit of Methodist Hospital also received adult doses of Heparin, and one might need surgery, said Sam Odle, chief executive of Methodist and Indiana University Hospitals. The other three were in serious condition.

Two babies born at 25 and 26 weeks' gestation died Saturday night, Odle said. Both were born in the last week, officials said. A full-term pregnancy lasts 38 to 42 weeks.

"These are very, very small babies," Odle said. "We are confident that no other infants except for the six were affected."

Heparin is routinely used in premature infants to prevent blood clots that could clog intravenous drug tubes, said Dr. James Lemons, a neonatologist at Riley Hospital for Children.

An overdose could cause severe internal bleeding, he said.

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How horrible!

How sad!

Poor little things never stood a chance

This is absolutely tragic - 6 lives could be lost. How in the world could a mistake like that be made? And then to have the director of the hospiital say: "Odle said. "We are confident that no other infants except for the six were affected." Except for is not acceptable.

These poor families must be in agony. God love them all. They are so small and helpless.


Scandi

scandi said:

This is absolutely tragic - 6 lives could be lost. How in the world could a mistake like that be made? And then to have the director of the hospiital say: "Odle said. "We are confident that no other infants except for the six were affected." Except for is not acceptable.

These poor families must be in agony. God love them all. They are so small and helpless.


Scandi

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Isnt it scary! People need to be MORE careful while giving meds, I had to give my son Robotussin just alittle bit ago because he has a cold and I am so anal, that I actually look at the bottle like 3 times just to make sure its right! I mean, when dealing with meds you cant be careful enough. The sad thing Is I have actually worked with Nurses who have given wrong meds and they act like "Owell, it was an accident".

LE investigated and found it to be accidental.....as horrible as it is. A staff member put the vial in a wrong drawer and when it was retrieved by nursing they didn't check the label for concentration specs before administering to the preemies. Both babies that died weighed less than one pound.

RubyJune said:

A staff member put the vial in a wrong drawer and when it was retrieved by nursing they didn't check the label for concentration specs before administering to the preemies.

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Well that is when your eyes help out, they should read the label. You ALWAYS double check when giving meds.

OMG I need to first start out by saying that I am an RN with years of experience on an LDRP unit. This is unbelieveable. You have got to be so careful when giving meds to these babies. Check, check and re-check and always along with another nurse. This should not have happened. Not only did it happen once it happened six times. There is such a thing as human error but in my opinion this is negligence.

scandi said:

This is absolutely tragic - 6 lives could be lost. How in the world could a mistake like that be made? And then to have the director of the hospiital say: "Odle said. "We are confident that no other infants except for the six were affected." Except for is not acceptable.

These poor families must be in agony. God love them all. They are so small and helpless.


Scandi

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That line bothered me too. I'm sure it wasn't meant that way, but it sounds as if he's saying, "Well, it was only six. Not a big deal considering it could have been worse." I don't think that's any comfort to the parents of those babies.

sleuthin4fun said:

OMG I need to first start out by saying that I am an RN with years of experience on an LDRP unit. This is unbelieveable. You have got to be so careful when giving meds to these babies. Check, check and re-check and always along with another nurse. This should not have happened. Not only did it happen once it happened six times. There is such a thing as human error but in my opinion this is negligence.

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Thank you, I am going to school now for my nursing degree, have worked in a local hospital for 2 1/2 years on the L&D unit many of times and I never have seen someone get meds without looking!!

michelle said:

Thank you, I am going to school now for my nursing degree, have worked in a local hospital for 2 1/2 years on the L&D unit many of times and I never have seen someone get meds without looking!!

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This is just my opinion but, there are two people that I am aware of that are at fault here. #1 being the person who placed the adult heprin in the neonatal drawer and #2 the one ultimately responsible the RN who administered the meds. Before that heprin was even drawn out of the vial she should have checked the label plain and simple. Drugs with these small infants are deadly if used in the wrong dosage. The label should have been checked by the nurse administering the drug as well as by another nurse, then the dosage should have been checked by both nurses then, after it is drawn into the syringe it should have been checked again. Now, this is pure speciuation but, here is what I would say happened. I say this because this was given to six infants. My guess is that since this is something routinely done the nurse grabbed the bottle out of the med cart, I would hope that she checked the label and saw that it actually said heprin on the bottle then my guess is that she drew up six syringes all with the same dosage of heprin and then went from infant to infant completing her task. I say this only b/c being a nurse you do what you need to do to get things done efficiently. As a nurse I can not even begin to imagine what she must be feeling. I feel just sick for her. I think that this was acase of pure carelessness. This is one for the textbooks and will be talked about in nursing schools and hospitals around the country for years to come.

Michelle, good luck in your nursing program. I hope you love it. It is one of the most rewarding jobs you could ever have.

sleuthin4fun said:

This is just my opinion but, there are two people that I am aware of that are at fault here. #1 being the person who placed the adult heprin in the neonatal drawer and #2 the one ultimately responsible the RN who administered the meds. Before that heprin was even drawn out of the vial she should have checked the label plain and simple. Drugs with these small infants are deadly if used in the wrong dosage. The label should have been checked by the nurse administering the drug as well as by another nurse, then the dosage should have been checked by both nurses then, after it is drawn into the syringe it should have been checked again. Now, this is pure speciuation but, here is what I would say happened. I say this because this was given to six infants. My guess is that since this is something routinely done the nurse grabbed the bottle out of the med cart, I would hope that she checked the label and saw that it actually said heprin on the bottle then my guess is that she drew up six syringes all with the same dosage of heprin and then went from infant to infant completing her task. I say this only b/c being a nurse you do what you need to do to get things done efficiently. As a nurse I can not even begin to imagine what she must be feeling. I feel just sick for her. I think that this was acase of pure carelessness. This is one for the textbooks and will be talked about in nursing schools and hospitals around the country for years to come.

Michelle, good luck in your nursing program. I hope you love it. It is one of the most rewarding jobs you could ever have.

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I hope people learn from this, it has to be devastating for the families and the nurse. Its sad all the way around. I hope I enoy the program. I think I will....I am excited about it but get nervous too...

I was once almost a victim of an excessive dose by a nurse. I was about to tavel abroad and needed a vaccination for typhoid fever. At that time, it was done with a shot (now you drink a liuid dose I beleive) and I had to get the vaccination at the pharmacy and take it to my doctor since they did not keep it in stock. The bottle was 5.0 mg. I was sitting in the examination room waiting for the nurse to come in and give me the shot. To bide time, I started reading the literature that came with the bottle. It said that the appropriate dose was 0.5 mg. I noted that this was 1/10th of the contents of the bottle. I heard two nurses approach the outside of the closed door. I overheard one tell the other to go in and to give the patient (me) FIVE mgs!!! I watched the nurse-in-training enter and go over to the counter and begin preparing the shot. I said to her, "You are going to give me 0.5mg and not 5.0 mg, right?" There was a long pause as she glanced at the paperwork. She seemed very embarassed as she acknowledged the mistake. I don't know if any of you have ever had the typhoid shot but it makes you sick as he!! for about 24 hours. You are actually injected with a small amount of typhus. I spent the entire next day on my couch unable to lift my head which was pounding and my joints ached. I'm told that the new version does not have this effect. I later told the story to my NEW doctor and was told that 5.0 mg would have likely KILLED me. l would have never have known the mistake had I not had the literature in had and been reading out of boredom. Since then, I always ask questions when I receive vaccinations and usually tell the doctor/nurse my story to prompt them to double check the dose!!!

My husband's family actually did lose someone due to an "accidental" overdose administered in a hospital many years ago. Check, check, and always ask questions when receiving medication. How tragic this is for the families of those babies and also for the person who administered the drug (as well as the person responsible for putting it in the wrong place).

What a horrible thing to have happened. I'm sure it was an accident but that doesn't make it less painful for the families of these babies. How they must have all been hoping and praying that their little ones would survive the early births and then to have that happen. So sad.

I think that hospital admin should watch the way he words things for pity sake. If one of those babies was mine and I read that I would be making my way to the Administrators office for a talk or shout!

Cypros...I'm sure glad that you were reading that material before you received the shot. That is pretty scary. I think that most of us just put our trust in the doctors and nurses to know what they are doing and never question it. I know I never ask questions when getting a shot or medication.
I just trust that they know their business. Thank God most of the time they do.

Bobbisangel said:

I think that hospital admin should watch the way he words things for pity sake.

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I think he simply was trying to indicate that they had already checked other distribution points for the heparin and that their investigation revealed that the adult dosage had not been stocked anywhere else where it might be administered to infants.

IndyLaw said:

I think he simply was trying to indicate that they had already checked other distribution points for the heparin and that their investigation revealed that the adult dosage had not been stocked anywhere else where it might be administered to infants.

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Yes, this is the way I interpreted his statement. I think he was trying to strongly reassure people that other patients were not at risk for this type of medication error. I was not offended by what he said.

This is so sad.When my son was in the nicu,everytime they gave him meds the policy is that another nurse checks to make sure it is correct.That was their policy.This hospital ought to consider doing the same.What a shame.

cynpat2000 said:

This is so sad.When my son was in the nicu,everytime they gave him meds the policy is that another nurse checks to make sure it is correct.That was their policy.This hospital ought to consider doing the same.What a shame.

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I agree. In many, many hospitals around the country, there is a procedure in place so that this does not and can not happen. In the local hospital here, which I just recently left (YEAH!) after working there for 13 years, it is routine policy first nurse #1 checks the meds & the dose, writes it down & signs for verification, and then nurse #2 does the same thing, and writes & signs for double-verification.

I wasn't offended by the words of the hospital admin, however if I was the PARENT of one of these children, you bet your sweet bottom that I would be HIGHLY offended.