Pharmacy mistake blamed for heparin overdoses at Texas hospital

July 11, 2008

At least 17 babies in the neonatal intensive care unit at a hospital in Corpus Christi, Texas, were given overdoses of the blood thinner heparin.

One baby has died and another is in critical condition after at least 17 in the neonatal intensive care unit at a hospital in Corpus Christi, Texas, were given overdoses of the blood thinner heparin.

Bruce Holstien, president and CEO of Christus Spohn Health System, said the problem was discovered Sunday, two days after the infants were given a more concentrated form of heparin than was prescribed.

A preliminary investigation by the hospital indicated the error occurred during the mixing process within the hospital pharmacy. Hospital officials said corrective measures have been taken.

Richard Davis, the hospital's chief medical officer, released a statement that said the baby who died "was seriously ill, and we do not know at this time what role, if any, the higher than expected concentration of heparin played in this baby's death. Our deepest sympathy goes out to this family."

Davis said 12 of the 16 babies are in stable condition, three have been discharged, and one is in critical condition.

This heparin overdose incidence is eerily similar to one last November when actor Dennis Quaid's newborn twins accidentally received 1,000 times the prescribed amount of heparin at a Los Angeles hospital. They survived, but consumer advocates are urging hospitals to embrace technology to reduce such errors.

"People need to ask whether their local hospital has a computerized medication system in place before they seek care. If they don't, they should ask why not?" Leah Binder, CEO of the Leapfrog Group, a Washington, D.C.-based employer coalition, said. "Studies suggest that (computerized physician order entry systems) reduce medication errors by 50% to 100%."

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