Let's talk about Heparin

Let me preface this post by clearly stating that I do not work in a NICU ~~

Now that I've gotten that out of the way, I'd like to discuss the recent neonatal deaths related to overdoses of Heparin. Some basic info for non-medical readers: What is Heparin?

"Heparin ( HEP-a-rin) is an anticoagulant. It is used to decrease the clotting ability of the blood and help prevent harmful clots from forming in the blood vessels. This medicine is sometimes called a blood thinner, although it does not actually thin the blood. Heparin will not dissolve blood clots that have already formed, but it may prevent the clots from becoming larger and causing more serious problems.......Heparin Lock Flush solution is used to prevent clots from forming in a venous catheter. This maintains access to veins in the body when multiple injections or blood samples are required."

Unless you've been living under a rock for the past few days, I'm sure you've heard or read about the 3 recent neonatal deaths in the neonatal ICU at Methodist Hospital in Indianapolis, where all 3 neonates died after receiving an accidental overdose of Heparin. Third Preemie Dies from Drug Overdose at Indianapolis Hospital

You might be asking yourself "how could something like this happen??"

Well, let's start with the checks and balances of a hospital. Most hospitals now have a computerized system of some sort to dispense medications for each individual patient. Where I work, it's called a Pyxis machine. Medications are stocked in the machine by a pharmacy technician in individual drawers, one drawer for each medication. Some drawers will hold narcotics, which need to be counted and the count needs to correspond with the correct number that remains in the drawer, or the nurse may not withdraw any of the medication. The nurse logs on to the machine with her own access code and password, then accesses the patient's medication profile (the pharmacy enters the profile information, usually only allowing the nurse to remove the medications that have been prescribed for the patient, though some systems allow an override of certain drugs). The nurse then chooses which medication she needs to administer to the patient, and the correct drawer opens up. If she needs to put in a drug count, she does that before she may remove the correct medication and dosage. After removing the medication(s) she closes the drawer, and logs out. Now, that's the technical part of getting a medication out of a computerized system. Some units stock routine medications in a locked medication room on shelves (such as saline flushes for IV's), and nurses do not go through the checks and balances as previously stated. However, for the majority of hospitals in the present day, almost every single medication or IV flush is locked up, and the nurse must go through the computerized dispensing system to access any of them.

Ok, fine, you may think -- everything is ok, right? She just gives the medication to the patient now, because it's assumed that everything is correct. Wrong. Now we have what are called the "five rights of medication administration" which have been drilled into every nurse starting at day #1 of nursing school. They are:

1. Right patient (checking the ID band on the patient, comparing it to the medication kardex that lists the medications)

2. Right medication (looking at the label on the med, to be sure it is the correct medication, and that the order in the chart matches what is in your hand. When in doubt, you refer back to the physician's written order.)

3. Right dosage (once again, looking at the label, referring to the medication kardex and the MD order if questionable. Also, you must ask if this dosage is too strong of a prescription, or too weak. Very important in all pediatric patients to make sure that the dosage per kilogram weight of the child does not exceed the recommended dose!)

4. Right method of administration (oral, IV, injection, etc)

5. Right time (8am, before meals, before bedtime, etc)

Once the nurse has completed all 5 of these checks - RIGHTS - only then should she/he administer the medication.

So, what went wrong? Where did the checks and balances break down in this system?

The first thing you notice about this hospital is that the pharmacy technician failed to stock the correct dosage of Heparin in the computerized medication system. He/she stocked a dose of Heparin that is 1000x stronger than what should have been in the drawer. The second thing you question is: did the nurses check the label on the vial? Did they really scrutinize what the label said, or did they just blindly draw up and push the solution into the IV, knowing that in prior episodes of removing the same medication from the drawer that it was the correct medication and dosage? Let's also look at one other item that has been overlooked in the news articles: WHY does the drug manufacturer make Heparin vials with a similar label and similar color tabs on the vials? Shouldn't the manufacturer have a different color on the top of the vial, or a different color on the label?

So where does the blame really lie for these 3 premature infant deaths? The pharmacy tech, the nurse, or the drug company? Is the hospital liable? Or is it a combination of all of the above?

Only time will tell, when the lawsuits are settled, if the blame will be placed solely or jointly on any of the persons and organizations involved.

My personal opinion? I believe that the fault lies primarily with the nurses. Yes, I may get flamed for my opinion, but the 5 rights of medication administration are there for a reason: to safely and accurately ensure that patients are not harmed. Yes, nurses in this day and age are very rushed to get everything done for their patients, and there is definitely not enough time in the day to get it all done. Nurses are overworked, underpaid, and stressed to the max. We are assigned to too many patients at times, creating unsafe situations for the very people we are here to help. But by skipping the very foundations of safety, we are putting each and every one of our patients at risk for medication errors, injury and potential death.

The pharmacy technician is also at fault, though at a lesser fault than the nurses in my opinion. He/she is responsible for accuracy in stocking the drawers in the computerized dispensary. I have not worked as a pharmacy tech, so I cannot tell you the checks and balances that I'm sure must be in place to make sure the tech fills each drawer with the correct med and dose. Comments from pharmacists or techs out there to help educate me on this topic?