Medication error puts most vulnerable at risk

According to the Institute of Medicine, medication errors are among the most common type of preventable medical mistakes to occur in hospitals. Unfortunately, seventeen premature newborns at a hospital in Texas were some of the most recent patients to experience such mistakes. 

According to a statement issued by Bruce Holstien, President and Chief Executive Officer of CHRISTUS Spohn Health System, seventeen newborns in the CHRISTUS Spohn Hospital Corpus Christi–South Neonatal Intensive Care Unit of were given higher than the recommended amount of Heparin over the July 4th weekend.   Heparin is an anti-coagulant often used to flush IV lines of patients to prevent blood clots from forming in the lines.

Once the CHRISTUS Spohn Hospital nursing staff made the discovery, the staff and physicians initiated immediate corrective measures to manage the effects of the medication. Their preliminary investigation indicates the medication error occurred during the mixing process within the hospital pharmacy. They have begun a full investigation to get to the root cause of this preventable medication error, which will take some time to complete.

It is still unkown at this time whether any of the newborns administered the higher-than-recommended doses of heparin have suffered any direct adverse events from the error.  Well-known actor, Dennis Quaid, brought a similar story to the public's attention when his own twin newborns were given overdoses last November. 

There are several different medication safety practices that could have helped to prevent the Heparin from ever making it into the IV lines of these newborns at an improper dose.  From improved medication labeling, to computer physician order entry to barcoding, there are processes hospitals can put into place to prevent medication errors.  Much more work needs to be done.