http://www.digitaljournal.com/article/257178
Posted Jul 9, 2008 by Nikki Weingartner

Texas Hospital Gives Dangerous Doses Of Heparin To Infants In Intensive Care Unit


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A blood thinning drug called heparin routinely used in the NICU for flushing IV lines and preventing blood clots from forming was said to have been administered to 17 premature and ill newborns in doses up to 100 times the prescribed amount.

One infant who was in serious condition prior to receiving the overdose, died at the hospital. An autopsy is scheduled, but the date and time has not been released. Another infant is in critical condition and has been that way prior to the incident. Twelve others are in stable condition and a records search has revealed that three infants may have been given the dangerous doses and released from the hospital.

According to a Corpus Christi News report:

a pharmacist and two pharmacy technicians were on duty when they accidentally mixed too much Heparin that was used to clear their IV's.
Two employees have requested to be on personal leave.

So what happens next?

Pending autopsy reports that should reveal any causative link to the infant's death, Christus Spohn South Hospital's CEO, Bruce Holstien made this statement: "We've been working on this for many, many years in hospitals. Errors do occur in hospitals, they're multi faceted, when you believe you have the answer we know that we liken this to the reference to Swiss cheese, there are holes that line up occasionally, in this case we'll do a complete investigation, that investigation will take several days to several weeks, it will be thorough investigation and we will come out stronger for it and learn from it and be able to share this with other health systems across the country."

In November of last year, one of Dennis Quaid's twin's was dosed with nearly 1,000 times the normal dose of heparin at Cedars-Sinai Medical Center in California. His baby was one of three infants in the NICU who received the dangerous dose. None of the babies suffered any ill effects.

In Indiana, several newborns died and several fell ill when a pharmacy technician mistakenly stocked a medicine cabinet with highly concentrated viles of heparin, which were in turn administered to the infants.

Despite the error at the Corpus Christi hospital, only one parent has transferred their infant. Safety verification processes have now been implemented to prevent this from happening in the future.

A frightening experience for all who are involved.