Heparin overdoses bring changes

October 23, 2006

Medication safety experts nationwide were dismayed but not surprised upon hearing the tragic news that three premature infants died after receiving a fatal dose of heparin at Methodist Hospital in Indianapolis. Three other pediatric patients who also received inappropriate doses of heparin were transferred to Riley Hospital for Children in Indianapolis where they were reported to be in critical condition at press time.

The absence of bar-code technology and a double-check system contributed to the fatal doses. "We've seen these elements before," said Diane Cousins, R.Ph., VP for U.S. Pharmacopeia's department of patient safety. She said that this event underscores the need for bar-code technology and second checks.

Officials at Methodist Hospital announced that they have implemented a series of drastic changes in hospital policy designed to prevent a similar event from happening again. Among the changes:

What happened?

According to a statement released by the hospital's CEO, a pharmacy technician took an adult dosage form of heparin from inventory and stocked it in an automated drug dispensing cabinet. Sources said the technician put in 10,000 units/ml, an adult dose, instead of Heparin Lock Flush-Injection (Hep-Lock, a diluted form of heparin) at 10 units/ml. The nurses, who are used to administering to infants, administered the wrong dose. Some patient safety advocates have called on Baxter Healthcare to change the labeling on heparin products so that there is a greater distinction between adult and pediatric doses. The current labels on adult versus pediatric heparin products are not identical, but similar.

Michael Cohen, M.S., president of the Institute for Safe Medication Practices, said that this type of mishap could happen in almost any hospital that uses a similar system. "Double checks must be in place, as well as limiting what you purchase and what you put in the cabinets," he said.

Cohen pointed out that hospitals need to assess their system for dispensing floor stock. "I'd be real careful about any injectable drugs that a nurse has to prepare or any high-alert medication that you place in a cabinet," he said. His advice to hospitals: Nothing goes out of the pharmacy and into dispensing cabinets without a two-check system.

In addition, Cohen said that if a hospital isn't looking into adopting bar-code technology, it is making a terrible mistake. "It should become a requirement."

Cohen has urged the Joint Commission on Accreditation of Healthcare Organizations to include bar-code technology in its National Patient Safety Goals initiative. Currently, adopting bar-code technology is not part of that initiative.

Henri R. Manasse Jr., Ph.D., ASHP executive VP and CEO, said that the latest high-profile med error should be a wake-up call for hospitals across the country to be absolutely certain that the right systems are in place to prevent medication errors. "Mistakes such as these are nearly always the result of a systems failure," he said. "It's vital that a systems approach is used to evaluate and prevent medication errors, rather than blaming an individual."

ASHP is calling on hospitals and health systems throughout the nation to conduct a critical and thorough self-examination of their medication use systems, including how medications are stored, prescribed, prepared, dispensed, and administered.