Cedars Was Warned Months Ago About Heparin Dangers

76. After seeing the bottles, I have a serious problem with Cedar people missing this. They are different colors/shades and the number of units on the label makes it very clear what the dosage is. The nurse giving the shot MUST look at what she is holding in her hand. There is no excuse, period! She is ultimately at fault IMO.

Posted at 1:43AM on Nov 22nd 2007 by BTExpress

77. To poster #11...
It is the NURSE who gives the meds...NOT the Dr. I would bet my butt (& thats a BIG bet!) the Dr. s orders read correctly...In this crazy day in age where the profits are more important than patients...we are understaffed this stuff happens. God bless the twins Mr. and Mrs. Quaid you're in my prayres and my heart goes out the the nurse who blew it...we have all been there at one time or another.

Posted at 1:59AM on Nov 22nd 2007 by Norm

78. Glad to hear they are going to be alright. Hang in there Dennis.

Posted at 2:17AM on Nov 22nd 2007 by Jason

79. I think color coding is a good idea. The problem might be that some of employees cannot read the dosages correctly .

Posted at 2:39AM on Nov 22nd 2007 by hmm seems like Ive heard this before

80. I cannot believe that something like this has happened but then again I can. First and most importantly JCAHO has strict guidelines on how to dispense medication. There should ALWAYS be 2 nurses that verify that the 5 rights are being honored 1)Right patient, 2)Right Drug, 3)Right route,4)Right dose, 5)Right time. These have to be followed AT ALL TIMES!! To not do them, puts not only the patient at risk but the nurse herself. The nurse is supposed to protect the patient. One of the first mottos you learn and you ALWAYS remember......FIRST DO NO HARM!! Now with that said, nurses are terribly overworked, work long hours and are short-handed. We definately need help. That is still no excuse, these things cannot happen,not where lives are concerned.

Posted at 2:41AM on Nov 22nd 2007 by nancy

81. Please watch the SICKO documentary by Michael Moore and really educate yourself. Our healthcare system is messed up and yes, there are many overworked staff working extra hours because there is a SHORTAGE of nurses in the good old USA !!!

Those who think they wouldn't make a mistake, should become a RN and find out first hand, why there is a shortage of RN's in our country. It is a huge liability to take care of those who want adequate and safe care when our hospitals won't and can't find enough nurses to work.

More and more sick people are coming...overweight, accidents, etc., and there is not enough RN's or LVN's to care for them. Think very carefully, how it is very easy to make a mistake!

There has been talk of training nurse assistants to administer medications without going to college as RN's and LVN's are declining due to many retiring and from burn-out. All hospitals don't have adequate nursing coverage and in the mean time, doctors keep admitting sick people for surgery in unsafe numbers.

I'm glad the babies are doing better and thankfully, and the error was caught in time.

Posted at 3:23AM on Nov 22nd 2007 by kat

82.

~ Happy Thanksgiving To The Troops!

Posted at 3:27AM on Nov 22nd 2007 by Troll

83. sure the vials look different to us in the bright light, close up and at our leisure. But to someone trying to take care of many patients at once, running here and there I'm not sure I would be able to always tell them apart if they were kept together without a very close look. Why are they in the near same color vials is the question if this issue has been on going at many hospitals, Enough so that a notice was sent out.
Put a happy face sticker on one for gods sake !

I do think the way the hospital stood up and took full responsibility was refreshing.
Ok I'm over this topic. Will keep babies my prayers and move on

Posted at 3:39AM on Nov 22nd 2007 by Janice

84. I heard a nurse today say they dont use that drug anymore to clean out the IV lines they use a saline soulution which is much safer. Of course I am not sure what the drug was used for on the babies. maybe someone who knows medical stuff can explain what this nurse was talking about and should it be used still?

Posted at 3:47AM on Nov 22nd 2007 by Kas

85. I have been a nurse for 23 yrs and am very aware of the incidents of error at a hospital setting. Believe it or not it is VERY easy to make a mistake. The health field has made some changes to try to prvent medicine error, but any time you deal with human involvment you deal with human error. So sad that I have not worked in a hospital setting for 12 years. Prayers go out to the family...

Posted at 7:42AM on Nov 22nd 2007 by Concerned

86. As several posters have already pointed out, as long as human beings are involved, mistakes will be made. But that said, as convenient as it is to place blame upon an individual or individuals, errors such as these are the result of system failures.

Many medication errors result from physician's poor handwriting, and the technology exists to "write" orders using hand held devices etc. But even in those relatively few hospitals who are willing to pay for such systems, such improvement efforts are not infrequently later abandoned due to physician complaints of not having time to learn or use the new system.

Similarly there are bar coding (and other) systems whereby the proper drug can be matched against the patient's arm band further reducing errors. But hospitals are not required to have such systems so many are unwilling to absorb the cost.

Hospitals have also forgotten their true function allowing so-called patient satisfaction /customer service to trump any inconvenience to their "customers".....so they permit families and patients interrupt nurses at any time while they should be checking their medications with care and without distraction during medication passes.

Staffing issues (both nursing and pharmacy) also contribute to medication errors. Many people would be surprised to learn that only one state mandates a minimum number of nurses per patient and hospitals often take advantage of that. (Ironically that one state is California, the state where this current tragedy occurred.)

As several posters have noted the medication vials could have been better differentiated by the manufacturer, and heparin vials of that high a dose should not be routinely available on the "floor". Certain high risk drugs (heparin and insulin) should also always be checked with another nurse before administration as a matter of policy.

I could offer numerous other examples which could dramatically reduce medication errors when taken as a whole. Unfortunately, it is all too easy to simply blame the nurse who incorrectly administers a medication instead of spending the time, money, and effort to repair the system.

Posted at 8:57AM on Nov 22nd 2007 by RLS

87. Baxter states that they are looking for ways to differentiate the
Adult and Child versions of their medicine so that hospital dopes
won't make that mistake again. There's one very simple way to do
this, Between the HEPARIN & 10,000 USP boxes place a RED Box stating
ADULT, on the Children's version a DARK BLUE box stating CHILD. The
choice of colors is important to prevent accidents by color blind
personnel. Reds can turn into shades of green or pink. Dark blue WILL
ALWAYS stay a shade of blue. Regarding the hospital, different
pharmacy forms, whether color or printing and keeping pediatric meds in a
separate location in the dispensory should be employed.

Posted at 9:40AM on Nov 22nd 2007 by Sparky

88. If the hospital employee, either working in the dispensary or the nurse has a form of color blindness called Deuteranopia, they would not be able to tell the difference between the colors of the caps. There might be a marginal shading difference, but the shading of yellow-green is perceived to be brown by them.

Baxter should reconsider the choice of colors for their caps to reduce this risk.

The hospital staff failed the children though.

Posted at 10:04AM on Nov 22nd 2007 by Sparky

89. As I am one, I can safely make the following statement:

Don't you just love these Monday morning quarterbacks?

We weren't there to see what types of distractions, the quality (or mental stability) of the staff employed or other issues involved. The introduction of adult meds in a pediatric ward is troubling though.

Posted at 10:08AM on Nov 22nd 2007 by Sparky

90. There are some hospitals who have given up the use of heparin, substituting saline for flushing these types of IV catheters. Looks like CSMC is behind, not leading, the curve.

Posted at 12:25AM on Nov 23rd 2007 by the Oracle