nabeepchen

It is a sad story of how two premature babies died because of human error. In this case, the error appears to have been that of a pharmacy technician, who sent up the wrong formulation of heparin–one meant for adults–to the NICU. The nurses were apparently unable to tell the difference, and this might have been because of the way the drugs were delivered to them.

From Medical News Today:

Two premature babies, one at 25 and the other at 26 weeks’ gestation, have died after being given adult doses of Heparin, a blood-thinning drug. A spokesperson for the Newborn Intensive Care unit, Methodist Hospital, Indianapolis, said the overdoses were due to human error. It has been reported that four more babies also received overdoses of Heparin at the same hospital. One of these four babies may have to undergo surgery as a result.

Heparin, which is commonly administered to premature babies to prevent blood clots, may trigger severe internal bleeding if the dose is too high.

An investigation is underway to find out how the errors could have happened. A hospital spokesperson said some steps have already been taken to make sure this does not happen again.

However, and I always have to have a “however,” I am wondering why this story is even in the news. Not that stories of medical errors aren’t important, but there are about 100,000 medical errors a year in hospitals. A lot of patients die, but they never get mentioned. It is interesting how news bureaus pick and select the tales of woe that they think will create the most interest and cause the most sensationalism. I guess hearing how tiny premature infants bled to death due to a pharmacist’s ineptitude is far more exciting than the 40 year old overweight man who just received an overdose of insulin, went into a coma and died. Or how that 56 year old woman was prescribed the wrong antibiotic, went into anaphylactic shock, and couldn’t be saved.

This particular article does point out that the hospital administers thousands of heparin doses each day and 100s of 1000s each year. Most patients have no problem, and dying from a heparin overdose is exceedingly rare.

Medical errors are a definite problem, and one due to any number of factors, such as understaffing and fatigue, and there should be public pressure for facilities to clean up their act. Hospital personnel should also be routinely refusing to take on assignments which lend themselves to error, such as too many patients, forced overtime, working in poor lighting, etc. But that said, I still wonder why a preemie death makes the news from a rare mistake. And it would be nice if writers might do a little snooping and find out what the situation is at this facility. What was staffing like for pharmacy when this happened? Who is the person who made the error? Was he being forced to work overtime? Was the lighting poor? Did he have too much to do at one time?

And what is the system like for checking drugs coming up from pharmacy? What is nursing staffing like in the NICU? Were the nurses so rushed that they didn’t look at the vial? Did they recalculate the dose?

That’s the problem with many of these news stories in that they only give a glimpse of a story.