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BNN News Archive Page
       Wednesday, September 20, 2006

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To Err is Human! But What When an Error Costs Three Lives

Six premature babies were given an ovedose of Heparin in the neonatal unit at Indianapolis' Methodist Hospital.Two died immediately and the third baby gave in after a long struggle with death.The three other fragile infants are seriously ill. The problem stemmed from a mixup of nearly identical vials of heparin.This resulted in the babies receiving an adult dosage of the drug, 100 times the prescribed dosage.

The hospital will offer to pay for family counseling and provide restitution to all six families.Hospital officials had met with family members and offered their apologies. But the families of these new borns would hardly feel better. Nor do we. Such chilling examples of negligence by hospital authorities need be examined more thoroughly and somebody has to be held accountable.It is time to question the hospital procedures.

Some mistakes are too costly to let go. Atleast some concrete steps should be taken to avoid repitition of such chilling errors. But do we have any hope there? Because this is not the first case of mistaken drug overdose.



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posted by PRAGYA at 1:57 PM  

2 Comments:

TucsonCleo said...

I might be able to believe this could happen in an emergency situation, like during a code. But I use to work as a Nurses Aid in a Preemie unit at the U or A. and I can tell you from first hand experience these nurses would never have "accidental" given a preemie the wrong dose of anything much less heparin. They would check and re-check the medicine bottle, the dosage, and the chart before administrating any drugs, but especially drugs like heparin. I don’t believe these were RNs, I’m thinking the hospital was trying to cut cost and using LPNs or NAs, but I can’t say. It’s a terrible tragedy for all involved. I don’t know how these hospital personal involved will be able to forgive themselves for being so careless.

Tucson AZ

2:12 PM  
PICURN2004 said...

I agree with tucsoncleo. I'm a RN in a pediatric intensive care unit and we would never administer medication or intravenous fluid to any patient without checking the physician order and then verifying the label on the fluid/medication container 3 times before administering to the patient. We are taught the 5 rights of medication administration in nursing school: Right patient, Right dose, Right time, Right medication, Right route of administration. Any reasonable nurse does this every time medication is administered. This is why it is critical that patients have a Registered Nurse at their bedside to assess them and be their advocate. Persons who have not been through nursing school have no business administering any fluid or medication to patients!!!! Stand up America. The Hospital Associations will have medication technicians giving you your meds as well as I.V. fluids if you don't make the legislatures listen now.

11:18 PM  

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