An autopsy is planned for a Corpus Christi, Texas infant to determine whether the blood- thinner Heparin may have factored into the newborn’s death.
Christus Spohn Health System reports the child was already seriously ill and was in the neonatal intensive care unit before he died, Tuesday morning. The child was among 17 premature babies in the unit to receive an overdose of the pediatric version of Heparin.
The error was discovered Sunday by hospital nurses who noticed abnormalities in a lab analysis. Pharmacy operations were reportedly halted temporarily Monday.
The FDA has been notified as well as the Texas Department of Health Services.
Bruce Holstien, president and CEO of the hospital, told local television that the anti-coagulant was used to flush IV lines to prevent blood clots from forming.
“On discovery, our staff and physician initiated immediate corrective actions to manage the effects of medication. Our preliminary investigation indicates the error occurred within the mixing process of the hospital pharmacy, Thursday, July third. The drug was administered July fourth, Friday. One pharmacist and 3 pharmacy techs were on duty. One of the two individuals involved has since requested personal leave. Our commitment is to prevent this from happening again. We are deeply sorry.”
Sherry Carr-Deer, spokesperson for the hospital, says that 13 of the infants remain in the NICU for reasons unrelated to Heparin; 12 are in stable condition and one remains in critical and unstable condition.
According to a statement, all of the babies who come into the neonatal intensive care unit NICU, are seriously ill. “Our NICU is a Level 3 facility for critically ill infants who are born prematurely, typically between 24 and 36 weeks. Many of these infants have low birth weights with multiple medical problems.”
A near-fatal Heparin overdose nearly killed the newborn twins of Actor Dennis Quaid and his wife Kimberly last November. They have since filed a lawsuit against Baxter Healthcare Corporation for failing to fix a blue label that looks similar in the low dose and high dose vials of Heparin.
"We all have this inherent thing that we trust doctors and nurses, that they know what they're doing. But this mistake occurred right under our noses, that the nurse didn't bother to look at the dosage on the bottle," Quaid told 60 Minutes in a March interview. "It was 10 units that our kids are supposed to get. They got 10,000. And what it did is, it basically turned their blood to the consistency of water, where they had a complete inability to clot. And they were basically bleeding out at that point."
In February, 2007, after the death of three Indianapolis infants who received Heparin, Baxter sent out a medication safety alert reminding healthcare professionals not to rely on the two different shades of blue labels when prescribing the drug.
Christus Spohn Health System is the region’s largest charity care provider and not-for-profit health care system.
Jesse Guerra, an attorney with Hilliard & Munoz, (an IB member) tells IB News, it’s the largest hospital in the area and the one that has been the focus of several lawsuits. Currently, his firm has one sexual harassment case filed by a patient who claims a nurse treated her improperly.
And discussions are underway in the wrongful death of a woman who was undergoing dialysis when the procedure at Christus Spohn was complicated by a blood clot. The 50-year-old woman’s daughter, who is a nurse, was with her while the dialysis was interrupted. Her mother died later that night and an independent autopsy, obtained by the family, showed that she died of a blood clot in her lungs.
Guerra tells IB News these are the cases they can take. The firm has to turn away at least two or three every month. That’s because in 2004, Texas voters approved a cap on medical malpractice of $250,000, regardless of the reckless nature of the doctor or medical personnel.
“I tell them you had to change the state constitution, you approved that. They’re devastated, ‘You’re kidding me-that’s my remedy” they say,” Guerra tells IB News.
Tort reform swept through Texas and Bay Area Citizens against Lawsuit Abuse and legislator Jaime Capelo headed the push. Now he is a lobbyist in Austin Texas with the Texas Chapter of the American College of Cardiology.
When the firm does take a medical malpractice case, it is try and make a difference. Last year, Bob Hilliard represented a hospital nurse who was murdered in the hospital parking area. The complaint alleged inadequate security and Guerra says, as a result, Christus Spohn has a new parking garage with improvements lighting, visibility, and security.
“I remember thinking Deborah (the name of the deceased woman) you’ve already made a difference,” he says.
Medical errors are believed to be responsible for harming at least 1.5 million Americans each year, sickened by medication errors according to an Institute of Medicine report released in 2006.
Medical errors are so prevalent, that a hospitalized patient can expect one medication error for every day he or she is in a hospital bed.
The errors cost hospitals alone more than $3.5 billion a year in treating drug-related injuries. #