Fatal Drug Mix-Up Exposes Hospital Flaws

The Associated Press
Friday, September 22, 2006; 9:34 PM

INDIANAPOLIS -- Early last Saturday, nurses at an Indianapolis hospital went to the drug cabinet in the newborn intensive care unit to get blood-thinner for several premature babies.

The nurses didn't realize a pharmacy technician had mistakenly stocked the cabinet with vials containing a dose 1,000 times stronger than what the babies were supposed to receive. And they apparently didn't notice that the label said "heparin," not "hep-lock," and that it was dark blue instead of baby blue.

Those mistakes led to the deaths of three infants. Three others also suffered overdoses but survived.

Now, their families, hospital officials and prosecutors are asking the same question: How could this happen?

Experts say last weekend's overdoses at Methodist Hospital illustrate that, despite national efforts to reduce drug errors, the system is still fragile and too often subject to human error.

"I see what happened here as depressingly normal," said Dr. Albert Wu of Johns Hopkins University, co-author of an Institute of Medicine report that estimated more than 1.5 million Americans a year are injured from medication errors in hospitals and nursing homes and as outpatients.

Methodist Hospital officials said they had safeguards in place before Saturday's overdoses.

Hep-lock _ a lesser dosage of heparin that is routinely used to keep intravenous lines open in premature babies _ arrives at the hospital in premeasured vials and is placed in a computerized drug cabinet by pharmacy technicians.

Nurses must enter their employee code and the patient's code into the cabinet's computer to open it. A drawer containing a large variety of medicines then opens, and they select the prescribed drugs from compartments and enter the amount withdrawn.

The system locks immediately afterward to prevent multiple withdrawals for the same patient. But there is no automated system to prevent nurses from taking the wrong medicine from the drawer in the first place.

According to hospital officials' account, a pharmacy technician had loaded the cabinet with heparin, at 10,000 units per milliliter, instead of hep-lock, at 10 units per milliliter.

D'myia Alexander Nelson and Emmery Miller died within hours of receiving the heparin. A little girl named Thursday Dawn Jeffers died late Tuesday. No autopsies were performed, but hospital officials said the cause of death was probably internal bleeding.

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