Indiana infants were accidentally given adult-sized doses of blood thinner
From MSNBC (AP)
INDIANAPOLIS - The grandmother of
a third premature infant who died after being accidentally given an adult-sized
dose of blood thinner medication at a hospital said Wednesday that she prayed
other families wouldn’t go through what she had, because it was hard “to sit
there and watch my granddaughter die.”
The baby girl, Thursday Dawn
Jeffers, died late Tuesday at Riley Hospital for Children five days after she
was born at Methodist Hospital. She had been transferred to Riley once her
condition worsened from receiving an adult dose of heparin, a drug routinely
given to premature babies.
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Point of View 
As a former neonatal intensive care unit nurse, I find the actions of the hospital personnel completely unacceptable. It goes without saying that the behavior, which lead to the deaths of these three preemies, was way below the accepted standard of care. This is so sad. These deaths could have been prevented so easily.
First of all, I really don't care that the pharmacy technician accidental left adult doses of heparin on the preemie unit by mistake. Yes, he/she was wrong and should be held accountable. No question. Mistakes happen. However he/she is not the primary person who should be held accountable.
The person who should be held the most accountable is the nurse who gave the patient the heparin dose. The nurse is always the person directly responsible for giving the medications.
This is basic nursing 101. Double check. Always double check! Certain safeguards are supposed to be in place to prevent just this type of tragedy. The very first one is to always double check the medicine and the dose to see that it's what the physician ordered!
This is basic standard of care that's used in every medical facility, on every single unit. This procedure has been in place for decades. It was among the very first things we were all taught way back when in nursing school.
Even when I worked in the preemie unit 20 years, we had certain other safeguards in place. Primarily, to always have two nurses check every single medicine before it's given to a preemie, to make sure it's the right patient, the right medicine, the right time, the right route of administration, the right dose. These are known among all medical personnel as the five R's.
I read in the article that the hospitals will now put the safeguard of having two nurses check the medicines into practice. They're just now getting around to this? That's inexcusable! There's no way their policies and procedures could be that far behind!
Many hospitals these days are using what's called the Pixis system. A wonderful system. It's an automated medicine cart that's computerized and filled by pharmacy. After selecting the medicine, a drawer pops open to allow the nurse to get the medicine out. It's supposed to help prevent medication errors from happening - and it does if it's used correctly. But we nurses have to do more.
We can't just rely on automated machines to dispense medications properly. We have to use our brains and our eyes too. Modern technology is great and has been a wonderful boon to the medical field. Computers are everywhere. Patients are diagnosed faster and more accurately, and the work load is much more streamlined - which helps everyone.
However, computers can't do everything. We shouldn't become too complacent, relying too heavily on computerized machines, to replace people who should be using their brains and practicing the skills they've been taught.
I feel bad for those nurses. I really do. We are only human and we all make mistakes. I can't begin to imagine what they'll have to live with for the rest of their lives. But I feel worse for the parents of those babies, and I feel more pain for them because it's their babies they will have to learn to live without.
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