Monday, September 18, 2006

Methodist Hospital Retraining Staff

In the wake of the accidental overdosing of six premature infants in the neonatal intensive care unit, which killed two of them, Methodist Hospital tells the Star that it has begun a re-education program for staff and implemented new procedures. The accident is the result of a pharmacy technician misdelivering vials of Heparin to the neonatal ICU with a does 1,000 times greater than they were supposed to receive. A nurse who retrieved the Heparin from a locked medicine cabinet did not notice that it was an adult rather than infant dosage. The Star writes:

A pharmacy technician with 25 years of experience accidentally delivered vials of heparin --- used to prevent the formation of blood clots in intravenous lines -- in adult concentrations to the neonatal intensive care unit, officials said. The vial looks identical to the one intended for the neonatal unit.

By Saturday, the hospital will complete its re-education program for staff, including procedures for ensuring they have the correct patient, dosage and medication. The pharmacy must doublecheck all drugs it takes from its stockroom before delivering them to the floors and at least two nurses must validate the doses before they're given to an infant.

The hospital also says it will no longer stock adult-strength Heparin. It is interesting to observe that a doctor at St. Vincent Women's Hospital told WISH-TV yesterday that it only allowed pharmacy technicians to deliver Heparin doses for infants to avoid the risk of accidentally administering adult strength doses. Yet, a pharmacy technician with 25 years experience still made that mistake at Methodist.

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