2nd Baby In Heparin OD Cases Dies
A second infant has died at a Corpus Christi hospital where an investigation is under way into overdoses of the blood thinner heparin given to as many as 17 babies.
The attorney for the infant girl's parents confirmed that she died Wednesday, a day after her twin brother died. The cause of the infant girl's death has not been determined. The Corpus Christi Caller-Times reported that hospital officials said the death of the newborn who died Tuesday was not caused by a heparin overdose.
An autopsy was performed on the infant but hospital officials declined to release the results, citing privacy rules.
Christus Spohn Hospital South officials said they could not discuss the second child because they had not received permission from the family.
The newspaper reported that the parents of the twins were granted a temporary restraining order that required the hospital to preserve records related the twins' hospital stay and overdose of the blood thinner heparin.
Attorney Bob Patterson said the twins were born at Christus Spohn Hospital Alice, located just west of Corpus Christi, on July 1, a month premature. They were transferred to Christus Spohn Hospital South the same day because it provides a higher level of care. He said the two began exhibiting symptoms of an infection after their transfer.
Two members of the Christus Spohn Hospital South's pharmacy staff have taken voluntary leave, pending an investigation that could take as long as two weeks, said Christus Spohn Health System spokeswoman Sherry Carr-Deer. State and federal agencies including the Texas Department of Health Services and the U.S. Food and Drug Administration have been notified.
Dr. Richard Davis, the hospital's chief medical officer, said in a news release that "the attending neonatologist states that at this point, there are no identifiable adverse affects directly caused by Heparin" among the infants in the neonatal unit. He said the infants still there were in the unit for reasons unrelated to the heparin, he said.
Carr-Deer said as many as 17 babies were given an overdose of the pediatric version of heparin. The hospital identified 14 babies that received an overdose but said it was possible that three others also had before their release. Follow-ups with those babies showed no ill effects, Carr-Deer said. Heparin routinely is used in the hospital's neonatal intensive care unit to flush intravenous lines and prevent blood clots from forming.
Carr-Deer said the hospital was not aware of the restraining order and could not comment. The newspaper said the filing also asked the hospital to preserve any unused heparin from the batch.
A preliminary investigation indicates that the error happened during a process July 3 in which pharmacy personnel mixed it with other solutions, including saline.
The heparin first was administered in the neonatal intensive care unit Friday.
The dosing error was discovered by nurses Sunday night, during routine blood work, Carr-Deer told the newspaper.
They discontinued the drug's use immediately and gave newborns who needed it medications to counter its effects.
Emily Palmer, a spokeswoman with the Texas Department of Health Services, said the agency was aware of the situation, but said she could not disclose whether there is a complaint or investigation because of confidentiality rules.
The Joint Commission on Accreditation of Healthcare Organizations, an independent, nonprofit agency that accredits and certifies more than 15,000 hospitals in the U.S. including those in the Spohn system, was notified, officials said.
In November 2007, actor Dennis Quaid's newborn twins were at the center of a near-fatal drug mix-up in which they were administered 1,000 times the normal dose of Heparin.
"We all have this inherent thing that we trust doctors and nurses, that they know what they're doing. But this mistake occurred right under our noses, that the nurse didn't bother to look at the dosage on the bottle," Quaid told 60 Minutes correspondent Steve Kroft in a March interview. "It was 10 units that our kids are supposed to get. They got 10,000. And what it did is, it basically turned their blood to the consistency of water, where they had a complete inability to clot. And they were basically bleeding out at that point."
Quaid's children recovered, and he has since testified before Congress in an effort to draw attention to what is one of the leading causes of death in America - preventable human, medical error.Read The 60 Minutes Interview With Dennis And Kimberly Quaid
"These mistakes that occurred to us are not unique," he told Kroft.They happen in every hospital, in every state in this country. And 100,000 people, that I've come to find out, there's 100,000 people a year are killed every year in hospitals by a medical mistakes."
The same avoidable mistake had occurred a year earlier at Methodist Hospital in Indianapolis. Six infants were given multiple adult doses of Heparin instead of the pediatric version; three of the infants survived, three did not.
During the past 18 months, there have been roughly 250 medical errors nationwide involving heparin and children a year or younger, according to U.S. Pharmacopeia, the public standards-setting authority for all prescription and over-the-counter medicines, dietary supplements and other health-care products manufactured and sold in the United States.