Cedars Was Warned Months Ago About Heparin Dangers

61. WHO caught the error? GOD bless the person who caught the error.
Nurses are made aware of this dangerous and common error, they recieve reminders that they are to read over and sign off on. ONE way to help stop this killing error is to change the labels to hot pink or red, like heads up lazy brained nurse.
I have seen so many medication errors and only because some nurse wouldn't ask a question to clarify, or just assumed the vile is the correct one without even reading it.
Back in nursing school the nurse is tested and tested and lectured about reading the label and calculating and yes, getting the calculation and the draw double and sometimes triple checked, but some don't do this.
This is an unforgiveable error, but nursing shortage, such as it is, will cause a tolerance for errors.
Usually a nurse will continue on the job with a write up, only if her mistake is caught, until a lawsuit, then she is allowed to work until the case is settled, if it goes to court and the hospital is found to be at fault and there is a settlement, then the nurse is fired, but she can quite before being fired.
THESE twin babies are very fortunate to have had the error discovered in time to save their lives.

Posted at 11:23PM on Nov 22nd 2007 by MICHELE

62. This is not a totally uncommon mistake - but very unforgivable in a hospital where there should be systems in place to double/triple check for human errors. My mother was issued a massive overdose of this medication following major surgery - the pharmacy made the error and she only caught it because the price was so high so she went to another pharmacy to see if she could get it for less. It would have likely killed her as she would have taken it after leaving the hospital. The lesson is that we all need to watchdog our doctors and our pharmacists...ask questions and be very, very aware of what you are taking.

Posted at 11:13PM on Nov 21st 2007 by lisa08021

63. .....Fly...hahaha...glad ur wings r dry...MANY have been asking abt u and where u r tonite!!..then there r the usual non humerous who actually respond to them!!!! haha...seems liek they missed ya too, but would NEVER admit it!! heehee

Posted at 11:19PM on Nov 21st 2007 by jr

64. ...FlyontheWall...seems quiet tonite with the holidays on the States...missing some of the regulars..anyway...fyi...I did a little resuscitation that u need to read abt on # 95 Quaid Medical screwup...I hope u don't really feel that !!...not busy here..Fly over if u get a chance..hahaha

Posted at 11:32PM on Nov 21st 2007 by jr

65. IF YOU WILL NOTICE, BOTH LABELS ON THESE BOTTLES ARE IN BLUE..ONE SLIGHTLY DARKER BLUE THAN THE OTHER !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
THE COMPANY FOR DOING THIS IS 100% IN THE WRONG, ALONG WITH THE NURSES WHO DID NOT TAKE THE TIME TO READ THE LABELS !!!! THIS IS THE BIGGEST MISTAKE OF THE YEAR !!!!!!! COMPANY NEEDS TO BE SUED !! IT'S SURPRISING THOSE TWINS HAVE NOT DIED YET !!!! IF THEY DO SURVIVE, WHAT ARE THE CHANCES OF PERMANENT DAMAGE TO THEM ????

Posted at 7:49PM on Nov 23rd 2007 by cheryl

66. I am a RN for over 16 years now,,,,,,,,,,,,,,,,,,,,most ppl have no idea of the extreme stress of such responsibility of other ppls lives, and the lack of help to care for those patients, when you have more ppl/ babies, etc. than you can care for,,,,,,you do the best you can and sadly, when you are overworked and overstressed, you make mistakes,,,,,,, sad thing is if you make one as a nurse it can be the ruin of your life. GOD HELP US ALL IN THE HEALTHCARE SYSTEM,,,,,,,,,,,,,,,,,,,,,,,,CAREGIVERS AND PATIENTS ALIKE.

Posted at 11:42PM on Nov 21st 2007 by Cathy D

67. ...hahahaha...I know. !! hahha

Posted at 11:51PM on Nov 21st 2007 by jr

68. I know it's not my business, but why didn't Mrs. Quaid carry and deliver the babies herself -- why a surrogate ?

I hope it wasn't simply more of the "got to look young and thin" mentality that led Dr. Donda West to her death.

Harvey, you are one of the chief promoters of the idea that we should all conform to a narrow standard of beauty.

Posted at 11:49PM on Nov 21st 2007 by For that I say, No Thanks, Turkey

69. The nurse(s) responsible should be fired, period. No "it was a mistake," the "company should make a different label," crap anymore. No excuses. Any person who works in ANY type of medical dispensing field knows you check, double check, and check again the label. It's pure laziness that ends up costing people- and innocent young children and babies- their lives. Fire them all!!!!!!

Posted at 11:51PM on Nov 21st 2007 by NoBrainer

70. there is no excuse for this mistake WHAT SO EVER!! even if the bottles a similar color the best way to make sure its the right one is to READ THE FREAKIN LABEL!!!

Posted at 11:58PM on Nov 21st 2007 by JAY JAY

71. OK..I was an RN for 20 years (ER/ICU) and have been an RPh for the past 8.5 years. I was the Director of Pharmaceutical Services at a hospital in CO, and according to JCAHO standards ALL large dose vials of heparin were taken off of the nursing floors (along with potassium) to prevent such an occurence from happening. Yes they are marked as to dose, and in a PIXUS machine they are kept separate, but the restocking of the machines are done by CPh (certified Pharm Techs). After stocking, they return to the pharmacy with a print out of what drug went into which drawer, how many were stocked, expiration dates etc... and the Pharmacist must sign off on the stock as well. So some of the blame rests here.
The nurses that administered all of the "wrong" doses were supposed to verify that the drug was correct, dose correct, route of administration correct and that the patient was correct 3 separate times prior to administering the drug. Once upon receiving the order, once again upon retrieval of the drug and the last time prior to administering the drug. Of course mistakes happen and I've made my share (none this serious tho), the problem that I have with this is that it occurred multiple times in the same hospital on the same day. Just doesn't add up. Since I've moved to LA I've seen so many errors, both in the paper and on TV, I am flabbergasted.
The obtaining of a license, especially if you are from OUT OF STATE (at least from Pharmacy's point of view) is horrendus. It has taken me 2 years (took the NAPLEX again here scored 119/135, but still need to pass the CPJE) to get to the point of being able to practice here in CA. It seems to me that CA needs new blood in their medical arena (pardon the pun) to relieve some of the stress and pressure on their staff.
My prayers are with the families injured and the personell that were involved. I can only imagine the heartache and grief each must feel.

Posted at 12:11AM on Nov 22nd 2007 by Assamite01

72. ...#70...not my area at all , but have notice many commenting on surrogacy...logic tells me that ANY woman who wants a child , ( other than adoption) ..would want to have the experience of pregnacy and birth, obviously many can't get pregnant, and if they can, their bodies reject the fetus, and they problable suffered alot of bitter sadness in the process...medicine has advanced now that for those who have tried and r't sucessfull , the option of surrogacy is there...u can use dads ( well u know) and moms ( well u know ) and get a helping uterus to do the job for ya...if both don't work then " helping uterus " can throw in a bonus of ( well u know ), heck , if dad's ( u know what ) isn't working , then mom & dad can get a donation of ( u know what ) for the hired help...got the drift??? hahahahahha...that was fun..

Posted at 12:13AM on Nov 22nd 2007 by jr

73. #76 assamite01

You all do a hell of a job, s h i t hits the fan sometimes, it's not a perfect world. Best wishes on passing the next exam.

Posted at 12:14AM on Nov 22nd 2007 by FlBiker

74. ......hahahaha...I'm tired and it is getting late...but i know i have to keep with the storyline...so abt ...surrogacy......FLY !!!!!!!!!!!!!!!!!!!!!...how to u insects mate anyways???????? hahhahaha...ok..that is bad but I am cracking up here!! hahah

Posted at 12:28AM on Nov 22nd 2007 by jr

75. After the Indiana incident, the drug manufacturer stated they would change the color of the labels so both would not be blue. Obviiously, they did nothing. Surely enough time has passed that they could have changed the label colors.

Posted at 12:30AM on Nov 22nd 2007 by peg