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Heparin medical mixup: Take Two

heparinmixup2.jpgE! News reports that Cedars-Sinai Medical Center has been given by the California Department of Public Health (CDPH) ten days to respond to a 20-page deficiency report concerning the medical mix up involving the drug heparin.

The incident transpired last November when nurses gave 1,000 times the needed dosage to three patients, two of whom were Dennis Quaid and Kimberly Buffington’s newborn twins. Though the twins and another patient did not suffer adversely from the mix up, it still resulted in a prolonged confinement for fraternal twins Zoe Grace and Thomas Boone, who were born on November 8.

Heparin is a blood thinner generally used when patients receive fluids through a central line to avoid clots forming in that line which can result in death. Too much blood thinner, however, could lead to life-threatening bleeding, or hemorrhages.

Cedars Sinai was quick to acknowledge preventable errors made by their staff in following standard procedures in the administration of a high-alert medication. The infants required only a 10 unit/milliliter dosage but were given a 10,000 unit/milliliter solution by nurses who failed to double check the labels. It was fortunate that a doctor noticed blood oozing from the twins’ IVs in time for the mishap to be corrected. The twins were given protamine to reverse the effects of heparin.

This is not the first time heparin featured in a medical mix up. Back in 2006, nurses at an Indianapolis hospital also made the same mistake which affected six patients and killed three. It could be two incidences too much for actor Dennis Quaid, who has filed a case against heparin-maker Baxter Health Care Corp. for creating a dangerous situation by using nearly identical labels for the 10 unit/milliliter and 10,000 unit/milliliter solution.

Cedars Sinai has already undertaken measures to re-train their medical staff, segregate the high-concentration heparin and review all policies and practices involving all high-risk medications. CDPH will decide on a course of action against the hospital pending their response.

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