Cedars Was Warned Months Ago About Heparin Dangers

TMZ has learned that the FDA issued an alert last February -- warning of the dangers of mistaking the low and high dose vials of heparin.

In the safety alert dated February 6, 2007, the FDA and Baxter Healthcare Corporation, one of the pharmaceutical companies that manufacture heparin, warned of the dangers of switching 10 and 10,000 unit vials of the drug. The alert was issued after three infants died in Indiana after they were mistakenly given adult doses. The memo tells hospitals to double-check their inventory to make sure errors in dispensing do not occur. We're told a memo with this information was also circulated around that time at Cedars-Sinai Medical Center. Despite the memo, the dispensing mistake happened last Sunday and Dennis Quaid's twins and several other patients were accidentally overdosed.

The California Department of Public Health says they are investigating the incident.



Reader Comments

(Page 7 of 7) Previous 15 Comments

91. Usually, a saline solution is used to keep the IV site patent. Flushes at least once a shift is what is recommended.

If the IV line is other than a regular hep-lock (means a tube is inserted into a vein, but capped. The difference is you're not attached to tubing and an IV pole.) than, normal saline flushes is all that is needed.

However, if someone has a PICC line, a central line IV site (both inserted into the heart) then yes, every time one utilizes it for blood draws, or give medications thru the line, then the line has to be flushed with normal saline, and the the LOW-dose Hep Lock solution is used to keep it patent.

I've never given the low-dose heparin to someone who had a regular IV site (arm/hand) as it was not required and normal saline flushes keep the IV site patent..

Maybe, it is is different protocol for babies (and maybe these particular babies had central lines rather than the regular IV site).

Or the nurse, for some reason, uses the Hep-lock solution on all IV accesses and if this is the case, she needs to stop.

Nevertheless, I hope all risk management departments (in the hospitals) throughout the country heed to the warnings and look out for patient safety.

Posted at 8:07PM on Nov 22nd 2007 by kat

92. 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 11:27PM on Nov 22nd 2007 by MICHELE

93. The Tec who misplaced the Heparin in the first place seems to have gotten off easy here, I find that odd.
It is his/ her only job to refill the meds in their correct order and place so that this stuff has less chance of happening, However I have compassion for everyone involved.
No one intentionally tried to kill babies, how horrible it must be to not only lose your career but live with that mistake the rest of your life.
Hope the children have no long term effects.

Posted at 12:10AM on Nov 23rd 2007 by Jamie

94. Why dont they change the blue nearly matching labeling and make the 10,000 a red label

Posted at 8:13AM on Nov 23rd 2007 by whateva

95. Those poor little babies

Posted at 9:51AM on Nov 23rd 2007 by www.sugar-shoes.co.uk

96. The fact those children were dosed wrong has absolutely "Nothing" to do with the fact there is "any type shortage or anything else".

The "Nurse or Doctor" that gave the medication did NOT follow protocol. There are five rights to giving medication.
1.Right Patient
2.Right Time
3.Right Route
4."Right Drug"
5. "Right Dose"

AND Not following that protocol is the worse thing a Doctor or Nurse can ever do. Not only that; When dosing a child. I would Never, Never, Never, give any medication without having a second nurse check that dose behind me. And neither would 'any good Nurse or Doctor' and to add fuel to the fire; I would have NEVER taken my most prized loved ones back to the scene of the crime. It is apparent that hospital needs a visit from the "State"!
This is just a small sample of what you will see if your illustrous Dems get into office and offer you that "Government Healthcare" they want to shove down your throats. It is called lowering your standards and accepting 'anything off the streets' to be nurses and doctors.

Posted at 8:02PM on Nov 23rd 2007 by E. Jones

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