Hospital Error – Heparin in the news again

Corpus Christi, Texas: Hospital error blamed for more infant overdoses – Yahoo! News

Key points of the story are:

  • 14 babies received heparin overdoses while in intensive care.
  • Two premature twins died, though it is unknown if this was the cause.

…pharmacy workers at Christus Spohn Hospital South made what the hospital called a "mixing error." The two workers went on voluntary leave.

The heparin, which was 100 times stronger than recommended, was given to 14 infants in the hospital’s neonatal intensive care unit on July 4.

As I have cited on previous posts, medication errors are one of the most common ways hospitals unintentionally injure or kill patients in their efforts to treat them.

I am reasonably certain that the two workers who went on "voluntary leave" (yeah, right) will absorb more than their share of blame as the system solves the problem by asking the "Five Who?" questions.

The article then goes on to cite a history of similar incidents in hospitals all over the country, though it is sometimes unclear in the writing if it is talking about this case or a previous one.

So what should happen?

First, determine where the actual root error occurred. If the manufacturer shipped mislabeled product, for example, then the problem happened THERE, not in the hospital. That isn’t to say we can’t do a better job in the hospital catching those things, but that isn’t the root cause in this case.

Any investigation should center on an assumption that the workers were operating in good faith, paying as much attention as can be expected of a normal human being, and were positive that they were doing this right. They did not want to injure or kill their customers.

Somehow, then, the process of mixing (either in the hospital or at the manufacturer) allows a 100x error to go by without SCREAMING for attention. And scream it must. Humans doing routine things in routine ways operate on an assumption that everything is routine until presented with overwhelmingly compelling evidence to the contrary.

Any hunt for "who did it" is motivated by extracting retribution rather than solving the problem. Once again, I refer the reader to the great work by Sidney Dekker on human error. We can all learn and apply it to everything that people need to do correctly – safety, quality, any other process or procedure.

5 Replies to “Hospital Error – Heparin in the news again”

  1. It was reported as a “mixing error.” Why they were mixing, I have no idea. Many hospitals (such as Cedar-Sinai, which injured the Quaid twins) buy two separate doses, where the mixup occur there.

    Here, maybe they only buy one dose and then dilute it for children’s use? That seems really risky and penny-wise, pound-foolish (but again, I’m speculating).

    As I’ve blogged about (and write about in my book), hospitals are too quick to blame individuals instead of looking at process.

    To be fair, the people who caused the error probably do feel terrible. It might truly be voluntary leave… many people leave healthcare because they’re devastated an error occurred. But the hospitals are often also quick to suspend or fire people, which isn’t getting to the root cause at all. Sad.

  2. I’m sure there is also a large legal component to the voluntary leave.

    Thank you Mark for your insight on this. Your concept of finding the “root error” hit’s home with me. I work with customer returns and I see the human errors that are made. At my company we have many inspection operations throughout the process. We manufacture parts for airplanes…

  3. I may have an idea for a visual poka-yoke that would apply whether it was a mixup between stocked doses or an error in diluting a standard solution:

    The stuff should be shipped with a certain amount of food coloring proportional to the amount active ingredient. The kids’ version would be visibly different from the adults’, and whether you’d mixed it wrong or grabbed the wrong bottle by mistake, you’d know.

    Does this sound at all practical? Is it a technique that’s ever been used elsewhere?

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