Heparin overdose scare in 14 babies at Texas hospital
Could CPOE have prevented this tragic error?
On July 4, 2008, in one of the more tragic medical accidents in recent memory, 14 babies in the ICU at Christus Spohn Hospital South in Corpus Christi, TX, received doses of Heparin that were 100 times stronger than the recommended doses, according to the Associated Press (AP). Two of the babies died, reported the AP, which also said the hospital blamed a "mixing error" in the pharmacy.
The hospital would not respond to repeated requests from HBQI for comments. In a prepared statement by Chief Medical Officer Richard Davis, MD, it was noted that all babies who come to the ICU are seriously ill, and that "the attending neonatologist states that at this point, there are no identifiable adverse affects directly caused by Heparin."
Errors concern The Joint Commission
The problem of medication errors in children is significant enough that The Joint Commission issued a Sentinel Event Alert on the topic on April 11, 2008. In the Alert, The Joint Commission made several recommendations, including the following:
- weigh all pediatric patients in kilograms, which then becomes the standardized weight used for prescriptions, medical records, and staff communication;
- do not dispense or administer drugs classified as high risk until the patient has been weighed, unless it is an emergency situation;
- use pediatric-specific medication formulations and concentrations when possible.
Donald F. Wilson, MD, medical director, Quality Insights of Pennsylvania (the state's QIO), agrees that problems can arise when medications for children are not measured in kilograms. "It can be a source of error when the caregiver does not think in kilograms," he offers. "For example, if you are thinking in pounds, you pay base your calculation on '70', when it should be closer to '30', for kilos."
Would CPOE help?
You have to assume human errors will occur, says Leah Binder, MA, MGA, CEO of The Leapfrog Group, and create systems to catch those errors. "When you have 14 of the same errors, you know the hospital needs to look into it," she notes.
"Obviously, CPOE can be a definite safety net, especially if you have an advanced system that knows the age of the patient and you have built into it the appropriate dosing," says Wilson. "Then, if the system sees you are ordering what would be a dosing error, it will ask you if you really want to proceed. It's an excellent way of preventing errors."
Type of system important
Binder agrees with Wilson's qualifier about the system. "You don't just plug in a CPOE system, and boom, you are covered," she explains. "You have to go through the hospital process, look at every single item that is ever prescribed, and make decisions about what kind of alerts you should place in the pharmacy for the prescriber, for the nurse at the bedside, and for the patient."
"CPOE can be extraordinarily valuable, but you have to identify the places where errors can happen," she says.
To improve the use of CPOE, says Binder, Leapfrog has added a required component this year that says hospitals will have to test their CPOEs. Her organization, she explains, has surveyed hospitals about CPOE, "and I can report anecdotally that hospitals have been very surprised at the way their systems seem to work," she says. "They are not as 'awesome' as they thought they would be. That's because [optimal installation] occurs only when the hospital customizes installation and tests the system very carefully."
[For more information contact:
Leah Binder, MA, MGA, CEO, The Leapfrog Group, c/o Academy Health, 1150 17th Street NW, Suite 600, Washington, DC 20036. Phone: (202) 292-6713. Fax: (202) 292-6813. E-mail: [email protected].
Donald F. Wilson, MD, Medical Director, Quality Insights of Pennsylvania. Phone: (877) 346-6180, ext. 7802.]
On July 4, 2008, in one of the more tragic medical accidents in recent memory, 14 babies in the ICU at Christus Spohn Hospital South in Corpus Christi, TX, received doses of Heparin that were 100 times stronger than the recommended doses, according to the Associated Press (AP). Two of the babies died, reported the AP, which also said the hospital blamed a "mixing error" in the pharmacy.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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