Preventable Medication Error Responsible for Infant Deaths

We’ve all read the articles that medical errors harm hundreds of thousands, if not over a million people every year. This time, an easily preventable medication error took the life of multiple infants. Lena Nelson had looked forward to buying dolls and other presents for her first granddaughter, who was born prematurely last week. Instead, she was planning Monday for the girl’s funeral.

D’myia Sabrina Nelson and another premature baby girl, Emmery Miller, died Saturday after they received an adult dose of a blood thinner at Methodist Hospital.

If this had happened in Texas, recent tort reform would have limited recovery to $250,000 per infant.

According to an article in the Seattle Post-Intelligencer, four other babies also were given overdoses of the drug. Three were hospitalized in critical but stable condition Monday at Methodist Hospital, said spokeswoman Jo Ann Klooz. The fourth was in critical condition at Riley Hospital for Children and continued to suffer from ill effects of the drug, she said.

Hospital officials said that the overdoses were the result of human and procedural error and that their hearts go out to the families, but Nelson said that doesn’t ease her pain.

“They couldn’t give me enough apologies for what they have done,” Nelson said. “They just took her away. It’s like murder. She was just taken away from us.”

Heparin, which is often used in premature children to prevent blood clots that could clog intravenous drug tubes, arrives at the hospital in premeasured vials. The vials are placed in a computerized drug cabinet by pharmacy technicians.

When nurses need to administer the drug, they retrieve it from a specific drawer, which then locks again.

Sam Odle, chief executive of Methodist and Indiana University Hospitals, said a pharmacy technician with more than 25 years’ experience accidentally took the wrong dosage from inventory and stocked it in the drug cabinet in the Newborn Intensive Care Unit. Nurses, who are accustomed to only one dosage of heparin being available, then administered the wrong dose.

The adult and infant doses have similar packaging, officials have said.

Odle said Monday that the three hospitals that make up Clarian Health Partners – Methodist, Riley and Indiana University – would no longer keep certain doses of heparin in inventory. All newborn and pediatric critical care units will require a minimum of two nurses to validate any dose of heparin. And nursing units will receive an alert when a change in packaging or dose is entered in the drug cabinet.

In addition, all employees will be required to sign a document about the importance of correct drug administration by Sept. 23.

Odle stressed that the hospital is “among our nation’s safest” and said Methodist would learn from the mistake.

The deaths came just days before the state was to approve a rule that would require hospitals to report errors.