Infant Heparin Incidents [ October 16th, 2008 ] Posted in » Root Cause Analysis - Incident Investigation

Root Cause Analysis :: Infant Heparin IncidentsIn 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.

UPDATE: US Beef Recall

I wanted to add a few more interesting facts on the recent beef recall as the ramifications continue to surface.  As a quick recap, on February 17, 143 millions pounds of beef were recalled.  For perspective, that’s enough beef to make every person in the US about two hamburgers.  The scope of the recall is rapidly expanding and it may become the largest food recall in US history.  The full magnitude of the recall is just now becoming apparent because it takes weeks to track down all the products containing the recalled beef.  Take a second to think of all the products in a grocery store that contain beef and you can imagine how large this recall is likely to become.  The amount of food that is going to be destroyed is mind boggling and the cost is likely to be in the hundreds of millions of dollars.  Keep in mind that no cases of illness have been reported, a large amount of the beef has already been consumed, and the U.S. Department of Agriculture classifies the risk to consumers as remote.  Does it make sense to destroy all this food? As you consider the scope of the recall, I ask you also to consider a root cause analysis of the problem.  The previous blog asked the question, what is the best approach to prevent this type of problem from happening again? I still don’t now the answer, but I do know that a recall alone does not solve the initial problems that caused the issue.  What cause really lead to sick cows being mistreated and then slaughtered for human consumption?    A recall deals with the problem after the fact and a good solution would change something in the process prior to the meat entering the food chain.  The USDA has stated that it will not be increasing inspections at food processing plants and I haven’t found any evidence that other changes are being made in the work process at the slaughterhouses.  I’ll be continuing to cook my meat well done.

February 26th, 2008 | Leave a Comment

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