Infant Heparin Incidents [ October 16th, 2008 ] Posted in » Root Cause Analysis - Incident Investigation
In 2006 in Indianapolis, 6 newborns were given adult doses of the blood thinner heparin. Adult doses are 1000x more concentrated than infant doses. Three of the babies died. In 2007, in Los Angeles, the same thing happened to three babies. Luckily none of those babies died. (The heparin overdoses that occurred in Texas in 2008 were caused by a different type of error.)
A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.
Overdoses of this sort impact the patient safety goal because they can result in fatalities and injury to newborns.
In order for this to have occurred, there were 5 opportunities for double-checking the dosage that were missed.
The wrong dosage was missed as 1) the bottle was removed from the pharmacy, 2) the bottle was placed in the cabinet, 3) the bottle remained in the cabinet, 4) the bottle was taken from the cabinet, and 5) the drug was adminstered to the babies. Some of the reasons that it was missed: there was no effective double check by another staff member, there was no check by a computer and of course due to human error, which was aided by the issue that the adult dosage bottle and the infant dosage bottle looked practically identical (this has since been remedied).
Many solutions to this type of error (such as requiring double checks by staff members and using a computerized prescription dispensation system) are already being implemented at hospitals across the nation.
The Hubble Space Telescope was launched on April 24, 1990. Once in orbit, it was quickly discovered that the images from Hubble were blurred. An investigation into the issue revealed that Hubble’s primary mirror was not built to specification and couldn’t properly focus the light. Specifically, the mirror was flattened too much away from the center and caused the light reflected from the edge of the mirror to focus on a slightly different location than the light reflected from the center. The primary mirror in Hubble was only off specification by 2.3 micrometers, but the result to the $1.5 billion dollar project was disastrous. 