oops!/Heparin Fatal Error in NICU (merged threads)

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I'm going to assume your oops comment was not made in jest - it was just a poor choice of word.

This mistake was/is far to easy to make & the people involved will never forget.

Hopefully....we'll all learn something from it & work to change oursleves & our way of working to prevent it from happening again.
 
i thought it was a good article for pharm students to read. how one small error can cost someone's life. i can't imagine how much guilt the tech must have...
 
fun8stuff said:
i thought it was a good article for pharm students to read. how one small error can cost someone's life. i can't imagine how much guilt the tech must have...
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Med errors like this occur because the error was overlooked at MANY levels...the tech was not the only one who made a mistake, and I'm sure looking back they will realize it could have been caught at several instances. Not to downplay the tech's role and how horrible they must be feeling right now though. But I agree with SDN77...hopefully this hospital and everyone else around the country will take a look at their procedures to see what they can do to prevent errors like this from happening!
 
When I worked in a hospital this nearly happened. We had a new guy who really didn't care about how well he did his job and he put the wrong strength of heparin in Pyxis, despite my previously having explained to him why he needed to be especially careful when stocking that drug. They were under a tech check tech program at that time and a senior tech missed his error. The time of discovery of the error was disputed - some nurses said it was found just prior to administration at bedside, some said it was in the drug room after pulling the drug. Anyway, the nurses figured it out before administration and prevented about 20 babies from being administered too high of a heparin dose. The new employee ended up getting fired based on that and his previous performance, which was less than exemplary. The sad thing was that he really had no remorse over the error.
 
Sadly, that was within my hospital system. It's so unfortunate that 3 of the 6 neonates died from this mistake. There is definitely going to be changes with heparin administration 🙁
 
WOW! So sad! I can't even imagine all the pain everyone involved is going through. When something like that happens I'm sure it affects everyone for a very long time.
Serious Simple terms : Pharmacy =life & death
 
I hope a lot of prepharms realize that this is part of pharmacy too. It's not all "Welcome to Walgreens" type stuff. For a positive out of this, we as pharmacy students and pharmacists can only strive to better ourselves and advance our profession. It's a terrible thing that happened but everyone must learn from this.
 
SpirivaSunrise said:


Med errors like this occur because the error was overlooked at MANY levels...the tech was not the only one who made a mistake, and I'm sure looking back they will realize it could have been caught at several instances. Not to downplay the tech's role and how horrible they must be feeling right now though. But I agree with SDN77...hopefully this hospital and everyone else around the country will take a look at their procedures to see what they can do to prevent errors like this from happening!
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Sad, sad, sad-I am sure everyone involved feels absolutely terrible, and agree completely with what SS said. If anything good can come from this, may it serve as a reminder for at least one person to think 'hmmm....I should quadruple check this' and may that person discover an error in time to make a difference.

I belive that no one sets out to make such an error, and having to live with making such a mistake would be punishment enough for most normal people (now the non-remorseful person described in another above post I don't really consider a *normal* person)
 
Great thread, it supplements a lot of what we've been getting in school so far. It drives home the responsibility that pharmacists have to be careful and thorough supervisors. Sure, the blame is being put on the pharmacy tech, but it's the responsible pharmacist who's ultimately going to answer for the mistake.
 
I haven't worked since the incident occurred, but the plan is for two nurses to check/verify the heparin med before administering. The babies were given the 10,000:1 strength instead of the 10:1 strength. Mistakes happen unfortunately---it would be so hard for me to return to work (with all of the guilt) if I was involved. We heard that the two nurses involved in the incident had to be escorted out by security because of death threats.
 
It's an important lession. That is why I always tell people who rush me to stop it because I am not going to make a mistake and harm someone so they can get their medications 5 minutes faster.
 
BME103 said:
It's an important lession. That is why I always tell people who rush me to stop it because I am not going to make a mistake and harm someone so they can get their medications 5 minutes faster.
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I perhaps too often rush to misjudge some of what you say....but your statement here is very eloquent!

No rushing is ever, EVER worth the risk of making a mistake.

They may never know the life you didn't harm, but you will!

I know of 2 pharmacists who made life-threatening errors & never were able to return to practice pharmacy, in spite of therapy in attempting to deal with it.

Remember - unless you are the person who must open that chest & give cardiac massage (& you'll NEVER be that person)....or something of similar medical significance.....the urgency you feel is all artificial & superficial! Take your time & DO IT RIGHT!
 
sdn1977 said:
I perhaps too often rush to misjudge some of what you say....but your statement here is very eloquent!

No rushing is ever, EVER worth the risk of making a mistake.

They may never know the life you didn't harm, but you will!

I know of 2 pharmacists who made life-threatening errors & never were able to return to practice pharmacy, in spite of therapy in attempting to deal with it.

Remember - unless you are the person who must open that chest & give cardiac massage (& you'll NEVER be that person)....or something of similar medical significance.....the urgency you feel is all artificial & superficial! Take your time & DO IT RIGHT!
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You mean I can stop our Stat TPN and Chemo now??
 
ZpackSux said:
You mean I can stop our Stat TPN and Chemo now??
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hahahaha! You know what I mean......The unnecessary "stats"! Being able to prioritize is an ability a pharmacist has a hard time learning.....one of the hardest I think. Especially since they, on any individual shift, may be the supervisors of the technicians. And...the technicians have their own idea of what takes priority. Some things, which seem routine, and actually are routine, are not taken as seriously as they should.

We have loved to fault "systems" in the past....however...what is your feeling as to the personal responsibility the individuals have to change the "system" to the situation at hand?

Take, for example, in a perfect world...you'd have a full staff.....all competent to do what needed to be done. However....on any given day or weekend, you're short staffed....but....someone puts pressure to continue to do what is expected - lets say its the last weekend of the month. The tech who is scheduled on has that weekend outlined to check outdates on 3 crash carts or whatever else "routine" you can think of. Now...you have that same person still doing that & being supervised by a young & inexperienced pharmacist who doesn't feel comfortable saying...no - lets let that ride this weekend, go help do the pyxis fill . That tech has 15 years of experience & says no - I have to do this now & your pharmacist with 1 year of experience says - ok...we'll make do.......Now you have pressure.

How as a dop do you give your pharmacists guidance in lessening the pressure to get the pyxis filled (or it could be the IV's made, or any of the other things....)? Mine gave no guidance & showed a lack of leadership in that regard.

The point is - i believe we as pharmacists must take responsibility for the system to work properly. When it is fully staffed.....it works. But....when it doesn't - we need to have the interpersonal skills to step up & say - no - this has become dangerous & I won't be pressured to do anymore than what I'm able to do safely.

I'm not just talking out my *#$.......I left a job for this very reason. The staffing was dangerous & was just a mistake waiting to happen.

I feel terrible for the staff involved (not to mention the families of the patients!). However....this may involve more than just the failure of a system....it may be a reflection of what we as individuals believe is right.

I'm not sure exactly where my feelings are.....too much is still unknown. I just know, I've been in these untenable situations before & they are terrible to have to live thru!
 
I overstaff my department. When administration doesn't like it, I always go back to "I can save you a million bucks a year in supply reduction or I can save you 50,000 a year on staffing." Take your pick and you can't have both.

Either that or fire me. I haven't been fired yet... but I keep pushing them.
 
ZpackSux said:
I overstaff my department. When administration doesn't like it, I always go back to "I can save you a million bucks a year in supply reduction or I can save you 50,000 a year on staffing." Take your pick and you can't have both.

Either that or fire me. I haven't been fired yet... but I keep pushing them.
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Yeah, yeah.....but you're one of the good ones. You know that is not the case everywhere & you know the situation exists.

What can we or should we do as practicing pharmacists do to help these young pharmacists develop a sense of taking their time to do what is right?

Each one of these folks may not be fortunate enough to work for a dop such as yourself or have the moral strength to quit a job as I have done.

I wonder (not that I necessarily believe - I'm just throwing out ideas) if we have abdicated our personal sense of the need to limit pressures put on ourselves to be able to work within the system - whether its hospital or retail. When, in actuality, we perhaps should be encouraging our young pharmacists and students to not just communicate clinical decisions,, but also personal professional ones as well...

Thoughts.....not as a specific dop....but as a colleague in a profession which has pressures which come from all sides to unnecessarily place patients in precarious circumstances?
 
Practice of Pharmacy isn't always about drugs and clinical. The other major component is the Quality and Risk management. It is imperative that I teach the National Patient Safety Goals to my staff. It's also very important for me to involve my staff in Medication Event Reviews and Adverse Drug reaction reporting process.

It is my responsibilty to assure that our pharmaceutical delivery system is conducive to preventing medication errors. There are checks and balance and multi level processes of assuring the right medication is processed by pharmacy and administered by the nursing. We have heavily invested in technology including bar coding and eMAR confirmation system.

This effort in turn allows the young staff pharmacist the importance of Zero Medication Error environment. Properly staffing and also hiring competent staff are vital in ensuring my medication delivery system is efficient and safe.

I take a few young pharmacists and call them my "grasshoppers." And I throw journals and guidelines at them... nonchalantly.. they take it home and read em in their bathroom I think.. then I quiz them... I also give them mindless projects..so they think. But I'm grooming them to become clinical pharmacists or future DOP.

But I understand that not every hospital pharmacy operates like the way I describe it... in fact very few. I can't change the world... but I can impact my world... Perhaps my grasshoppers will see it the way I do and spread the gospel as I preach.
 
From what I understand, heparin is one of the more common hospital mis-fills. One issue, at least when I was working hospital, is that the packaging for each strength is the same size, color, and layout, with the labelled strength really being the only stand out difference in packaging. You'd think ISMP or some other group would raise a fuss or something.
 
bananaface said:
From what I understand, heparin is one of the more common hospital mis-fills. One issue, at least when I was working hospital, is that the packaging for each strength is the same size, color, and layout, with the labelled strength really being the only stand out difference in packaging. You'd think ISMP or some other group would raise a fuss or something.
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Actually, its less common than it used to be. Perhaps the poster who actually worked at the institution can provide some perspective...however......I'd caution that individual to be circumspect!!!!

A public thread is just that - public...so less said the better.

However...in my institution...the heparin lock flushes were only in one adult strength & one pedi strength. The pedi strength is kept in a completely separate & isolated place from all the other heparin. You have to go out of your way & read many alerts to actually pick each heparin.

We also only keep one strength of heparin for subcutaneous injection. Heparin infusions are premixed & of only one strength...so there is no possibility that a tubex of heparin can be used to mix an infusion. Standing orders prevent anything other than the standard premixed infusion.

The labeling has been changed to make it clearer & IMO - it is extremely clear! But...we read what we expect to read....Sometimes we get so used to things...we stop reading!
 
ZpackSux said:
Practice of Pharmacy isn't always about drugs and clinical. The other major component is the Quality and Risk management. It is imperative that I teach the National Patient Safety Goals to my staff. It's also very important for me to involve my staff in Medication Event Reviews and Adverse Drug reaction reporting process.

It is my responsibilty to assure that our pharmaceutical delivery system is conducive to preventing medication errors. There are checks and balance and multi level processes of assuring the right medication is processed by pharmacy and administered by the nursing. We have heavily invested in technology including bar coding and eMAR confirmation system.

This effort in turn allows the young staff pharmacist the importance of Zero Medication Error environment. Properly staffing and also hiring competent staff are vital in ensuring my medication delivery system is efficient and safe.

I take a few young pharmacists and call them my "grasshoppers." And I throw journals and guidelines at them... nonchalantly.. they take it home and read em in their bathroom I think.. then I quiz them... I also give them mindless projects..so they think. But I'm grooming them to become clinical pharmacists or future DOP.

But I understand that not every hospital pharmacy operates like the way I describe it... in fact very few. I can't change the world... but I can impact my world... Perhaps my grasshoppers will see it the way I do and spread the gospel as I preach.
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Good points!!!! And my point exactly, altho better spoken.

When we pharmacists give students or less experienced pharmacists tasks which seem to have no apparent purpose....part of it is to educate you to learn things which are not necessarily drug related, but definitely clinically related.

You need to learn the interpersonal skills to be able to keep your technicians focused on the detail of what is a very boring & repetitive job. You also need, no matter the practice setting, to be able to set limits - whether its with your dop, your technicians, your store manager, your crabby patients....to not push you into not being careful.

Risk management should be a required course not just at the beginning of pharmacy school, but also at the end. It would also be helpful if its required as CE occassionally. My husband's dental malpractice requires him to take a risk management class every other year. Perhaps we need to think about that as well.

As ZPack stated...we can't change the world of pharmacy...but...we can - each in our own way...make an impact to stop the craziness!! It starts with just one individual. Just think if yours had been the initials on that pyxis fill - that person will never, ever forget it!
 
We actually had to read this article for Law class and are going to be tested on this. I think it just showed the importance of Risk Management.
 
http://www.clarian.org/portal/patients/news?clarianContentID=/health/announcements/20060918_odle.xml

Very unfortunate incident. I bet finger pointing is flying rampant in that hospital. But before they point fingers at Pharmacy with punitive intentions, the hospital administrators better be prepared. If I was the DOP who was under a constant staffing and budgetary strain from the administration to provide safe pharmaceutical care, I'll make sure the administration takes the full responsibility for the incident.
 
It is with deep regret that we report that two premature infants died and four other infants were affected Saturday evening, Sept. 16, in Methodist Hospital's Newborn Intensive Care Unit, where the hospital's most fragile patients receive care. It appears, preliminarily, that vials with an inappropriately high level of Heparin, a blood-thinning agent, were mistakenly administered to six infants in place of those with the lower, correct dose.

Once it was determined that incorrect doses were administered, Methodist physicians and nurses immediately commenced corrective procedures. We are confident that no other infants outside of those six have been affected and that all children in the Methodist NICU are safe and receiving the very best care.

We are currently conducting a thorough investigation of all facts and circumstances surrounding these events, but it appears that procedural errors are responsible for these tragic deaths.

We administer thousands of doses of Heparin each day and hundreds of thousands annually -- this was extremely rare and isolated given our existing safety measures. We have corrected the immediate problem, and we are conducting a comprehensive investigation to further improve our quality and safety policies and procedures for the benefit of all our patients.

This is a tragic event and our thoughts and prayers are extended to the families. When something like this occurs, we are all affected from the nurses at the bedside to the CEO. All of us are in health care because of our unwavering commitment to helping people and this incident hurts us all. Again, our hearts go out to the families, and while we realize that there is nothing that we can say to alleviate all of the pain, we want to continue to extend our assistance and support to them in any way we can.

We are investigating this incident to ensure that we can work to eliminate error as part of care delivery. Our mission is to deliver high quality care and to deliver perfect care in terms of safety and this is a priority for all patients and families.

Again, we want to emphasize that all NICU patients are safe and receiving the appropriate course of care.

As we move forward with the investigation, we will continue to provide more information as we learn more.
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Procedural Error? At least they hope...

This could have been prevented if they're utlizing bedside bar code technology using manufacturer's bar code along with proper staffing in the pharmacy and nursing units. Of course staffing during weekend evening is very thin...

Yes, I'm pointing fingers at the administration.. and this isn't really like me.
 
👍

Hence....my previous post on risk management. I know you listed all the subsections, etc, etc, etc......

But...when it comes right down to the bottom line...we as individual providers need to decide our own personal choices in what position we will or will not work in.

As a dop....yours is different from mine. I chose to walk away from a job in which staffing was dangerous & my circumstances were precarious. That was before bar coding technology was commonplace. Its good you take the time to take off your dop hat & become plain old pharmacist who has to make the procedures work & who must supervise those who may or may not necessarily see the significance of each individual product they manipulate.

However, if I was a new grad....or one who was wanting to bite at the headhunters who call trying to staff hospital positions on a weekly basis....I'd make damn sure the staffing was such & the technology was in place so I was not subject to situations in which my ability to make clear decisions was affected.

There are all these threads on how busy we are, how much pressure we have, etc.....but....it comes down to a personal choice. In a hospital...the dop & QC pharmacist make sure the procedures are in place, staffing is sufficient, etc ...however...it is the individual AT ANY GIVEN TIME who must make the choice of saying Stop! Risk management is a concept which is not just on a corporate level - it is a personal one as well.

At some point....you make the choice to stay or go. I left because I never wanted to be the initials on the pyxis (or in my case the chemo) fill list which was perhaps proximate in the direct cause of a tragic event such as this. THE MONEY IS NOT WORTH IT!
 
You would love my pharmacy.
 
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