Infant Heparin Flush Overdose

The news media recently reported that three premature infants died at a Midwestern hospital after receiving an overdose of heparin last weekend. Two, possibly three, other babies also were affected but are not in danger. Apparently, 1 mL heparin vials that contained 10,000 units/mL were placed incorrectly into a unit-based automated dispensing cabinet where 1 mL, 10 units/mL vials were normally kept. The vials looked very similar (see Figure 1).

Several nurses requested 10 units/mL vials to prepare an umbilical line flush and were directed to that drawer, but did not notice that the vials contained the wrong concentration. No doubt there’s a lot more to the story but, for now, we have to say that similar medication errors could probably happen in most hospitals.

Automated dispensing cabinet filling errors are quite common. Please take a close look at your own restocking processes. Having a double-check of items before they leave the pharmacy is an important way to prevent mistakes, but even that is not fool-proof. Wherever possible, hospitals should avoid stocking items on nursing units that require further preparation by nurses before administration. As you examine your own practices, pay special attention to cabinets that are used for neonates and pediatric patients, since these are especially high-risk patients. For example, assess the medications and strengths that are stocked in cabinets.

The hospital involved is lowering the 10,000 unit strength of heparin. Perhaps this is time for you, too, to consider what might be removed for safety sake. Although not a factor in this case, this is also a good time to examine which medications are being removed from the cabinet without a pharmacist's review.

Also, even with the perceived safety of automated dispensing cabinets, hospitals should take steps to minimize look-alike packages and labels. Finally, if you aren’t already discussing bar coding at your location, it’s time to do so. FDA began requiring bar codes on drug containers for a reason—to help all of us prevent medication errors. Bar coding is valuable for bedside scanning to confirm the accuracy of the patient, drug and dose. But even without bedside scanning, cabinet vendors also provide bar code systems for assuring proper medications are stocked. We don't profess to know the easy answers, but this tragic case brings to light a serious national problem about which all should be concerned.