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.