Technology and better standards would help reduce medication errors such as the one that led to 14 babies receiving overdoses of the blood thinner heparin, safety advocates said.
Last week, Corpus Christi, Texas-based Christus Spohn Health System announced it had discovered a mixing error in its pharmacy had led to the babies receiving up to 100 times the typical 1 milliliter dose of heparin for infants in the neonatal intensive care unit at its Christus Spohn Hospital Corpus Christi-South Campus. Two of the babies, a set of twins, have since died, but their deaths were not believed to be directly linked to the overdose, according to a spokeswoman. The Joint Commission is reviewing the case, and Christus Spohn is conducting an internal investigation.
While serious medication events are rare, they continue to happen because of a lack of standards, said Michael Cohen, president of the Institute for Safe Medication Practices. There is no standard way to administer heparin to infants, he said. The drug does not come in a standard pre-mixed package or dose; the pharmacists have to measure it themselves, he said. That leaves a window for errors, such as mathematical mistakes or picking up the wrong container, he said.
Standards would ensure pharmacists were using the same recipe to mix drugs with the same concentrations, and bar coding would help reduce wrong-container errors, Cohen said. The institute publishes a newsletter to help hospitals follow drug-safety best practices.
This is the third high-profile incident of heparin overdoses among babies. Last year Cedars-Sinai Medical Center in Los Angeles administered a thousand times the intended dose of the blood thinner to actor Dennis Quaids infant twins. In 2006, heparin overdoses killed three children at an Indianapolis hospital. Both of those incidents could have been avoided if the facilities had utilized bar-coding technology, Cohen said.