Yet another Heparin error!!

[Guest guest]

Hi All-

Here's a link reporting that up to 17 babies received the wrong dose of

heparin. AGAIN!!! This time it looks like the doses were " prepared " in

the pharmacy. Arggggh!!!!

http://www.chron.com/disp/story.mpl/ap/tx/5880328.html

Dora

[Guest guest]

Dear All,

The last line says it all and is WHY we MUST have mandated EDUCATION and

TRAINING NOT just one or the other for pharmacy technicians across the USA!!

" 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. "

Thank you Dora , moderator of this site for this post and your

continued effort to educate and inform us all.

Respectfully,

Jeanetta Mastron CPhT BS

Founder/Owner

> From: doracpht <doracpht@...>

> Subject: Yet another Heparin error!!

>

> Date: Thursday, July 10, 2008, 7:30 AM

> Hi All-

> Here's a link reporting that up to 17 babies received

> the wrong dose of

> heparin. AGAIN!!! This time it looks like the doses were

> " prepared " in

> the pharmacy. Arggggh!!!!

> http://www.chron.com/disp/story.mpl/ap/tx/5880328.html

>

> Dora

>

>

> ------------------------------------

>

>

[Guest guest]

Heparin questions ?

I found two videos and some documents that may interest you as a tech regarding

recent heparin overdoses. An autopsy will be performed to determine the cause of

death.

Officials Investigate Infants' Heparin OD at Texas Hospital

video and transcript:

http://abcnews.go.com/GMA/Parenting/story?id=5346509 & page=1

Since then, drugmaker Baxter International has increased the size of the label

by 20 percent and added red warning signs to adult doses.

Vaida, executive vice president of the Institute for Safe Medication

Practices said " The one thing with heparin is the concentrations

of the product you have a one unit all the way up to 20,000 units, and there's

at least about six or seven concentrations in between, so it's not uncommon for

these different concentrations to be mixed up.

Vaida also said one possible solution is to use bar coding.

" We've always advocated the use of bar coding, " he said. " Many hospitals have

bar coding in place now and what would help — when you're preparing the

product, you could bar code the vial and then also bar code whatever preparation

that you're mixing up. Also the nurse at the bedside could bar code either the

syringe or the vial. "

Video

http://www.msnbc.msn.com/id/21134540/vp/25643417#25643417

http://www.msnbc.msn.com/id/25637545

Infant deaths raise new heparin questions

17 babies hurt after receiving blood thinner in Texas pharmacy mix-up

http://www.msnbc.msn.com/id/25637545/

" Cedars-Sinai instituted additional training and required that four pharmacy

technicians verify such “high-alert†medications before putting them in any

hospital units. "

Respectfully,

Jeanetta Mastron CPhT BS

Pharm Tech Educator