Heparin Overdose Suspected In Texas Hospital Baby Death, 16 Others Affected

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Main Category: Pediatrics / Children's Health
Also Included In: Blood / Hematology;  Pharmacy / Pharmacist;  Nursing / Midwifery
Article Date: 09 Jul 2008 - 9:00 PDT

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Reports are coming in that a hospital in Texas, USA, is investigating how up to 17 babies in a neonatal intensive care unit (NICU) received an overdose of the blood thinner heparin; one of the babies is dead although the cause of death is not yet known.

A CNN news report said that officials at Christus Spohn Hospital South, located in Corpus Christi, a coastal city in south east Texas, have put "corrective action" in place after they discovered the overdose.

Dr. Richard Davis, Chief Medical Officer of Christus Spohn Health System said in a statement issued yesterday that the baby who died was very sick 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". He expressed deepest sympathy for the family, and at their request has not revealed any names or other details of the baby's treatment.

Davis said that three of the other 16 babies have since been discharged and gone home, and one remains critical and unstable, and "has been in that condition since admission several days prior to this event". The remaining 12 babies are stable and remain in the hospital's NICU.

Heparin is often used to flush out intravenous (IV) lines to stop blood clots forming in the tubes.

In November last year, 12-day old twins Thomas and Zoe, whose parents are Dennis Quaid and his wife Kimberly Buffington, nearly died when they were accidentally given a dose of heparin that was 1,000 times bigger than prescribed when they were 12 days old.

Quaid, who gave evidence to a House Committee on Oversight and Government Reform at Capitol Hill in May this year, said there were two similar looking doses of the blood thinner sitting on the same shelf and the wrong one was taken down and given to his babies. He said he and his wife don't know what the long term effects of the overdose might be.

Staff at the Corpus Christi hospital first realized there was a problem on Sunday, two days after the blood thinner was first administered, Bruce Holstien, president and CEO of Christus Spohn Health System said in a press statement that an initial investigation concluded that:

"The medication error occurred during the mixing process within the hospital pharmacy last Thursday, July 3rd. The medication was first administered Friday, July 4th."

Holstein said it will take some time to complete a thorough investigation to get to the root cause of the preventable medical error.

He explained that one pharmacist and two technicians were on duty when it happened, and that:

"Of the two individuals involved in this particular instance, both have since requested to be placed on personal leave."

Holstein said that the health system's pharmacies have very specific procedures for preparing medications, and acknowledged that in "this case, something went terribly wrong".

Source: CNN, MNT archives, Christus Spohn Health System.

Written by: Catharine Paddock, PhD
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today