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Hospital Changes Procedures After Babies' Fatal Overdoses

POSTED: 7:13 pm EDT September 18, 2006
UPDATED: 8:30 pm EDT September 18, 2006

Methodist Hospital is requiring nurses and pharmacy workers to double-check labels of an anti-clotting drug and is banishing certain doses of the medication after two infants died of overdoses over the weekend, 6News' Tanya Spencer reported.

Hospital officials said six premature babies were accidentally given adult doses of heparin at Methodist's newborn intensive care unit. The mistake was caught and the six were treated, but two of them -- 2-day-old Emmery Miller and 5-day-old D'Myia Nelson -- died Saturday, officials said.


Video: Hospital Changes Procedures After Babies' Fatal Overdoses

A coroner determined the deaths were accidental.

One of the surviving babies was taken to Riley Hospital for Children and was in critical condition and not stable on Monday. That baby continued to suffer from ill effects of the drug, spokeswoman Jo Ann Klooz said.

The other three babies were in critical but stable condition Monday at Methodist Hospital and were no longer showing ill effects from the heparin, Klooz said.

Methodist Hospital President Sam Odle said human and procedural errors were to blame for the overdoses.

Heparin arrives at the hospital in premeasured vials and is 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.

Early Saturday morning, a pharmacy technician with more than 25 years' experience accidentally took the wrong dosage -- vials of 10,000 units of heparin -- from inventory and stocked it in the drug cabinet in the newborn intensive care unit, Odle said. Five nurses, who are accustomed to only one dosage of heparin -- 10 units -- being available, then administered the wrong dose.

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

Starting immediately, Odle said, all Clarian hospitals -- which also include Indiana University and Riley Hospital for Children -- will no longer keep vials of 10,000 units of heparin in inventory.

Also, all newborn and pediatric critical care units will require a minimum of two nurses to validate any dose of heparin, and two pharmacy workers will be required to check the drugs being loaded into the cabinet. 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.

The nurses who administered the adult dosages to the babies and the pharmacy technician who stocked the cabinet with the dosages are receiving counseling and are expected to return to work, 6News reported.


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