Mark Graban at Lean Blog asked the following question as a comment to a posting below. It is interesting and important enough to repeat here for a larger audience -- and particularly for people at other hospitals who might find the answers of value. I am sure the BIDMC people mentioned would be very happy to provide further information to people from other hospitals. (Also, I have to admit to a little pride in that our folks, who already thought they had a very good plan on this matter, went further to adopt additional safeguards for these very tiny babies.)
"Do you have thoughts to share on the preventable heparin error involving Dennis Quaid's twins in L.A.? What steps is BIDMC taking to proactively prevent that same error from occurring in your hospital?"
After consulting with our people, I posted this initial response, with the help of Greg Dumas, one of our pharmacists:
I asked our folks about the heparin question you raised. Here is part of the response from one of our pharmacists. As you can see, the staff is still working on other ideas.
"Please see the steps below that we put in place prior to the tragic September 2006 incident at Methodist Hospital in Indianapolis.
"1) Heparin Flush Syringes 10 unit/mL are stocked in the NICU Automated Dispensing Machine(ADM). These syringes are stored separately from adult heparin products in an area designated for "Neonate Use Only".
"2) All medications that are filled in the NICU ADM are checked by a pharmacist prior to delivery.
"3) All heparin containing intravenous fluids are prepared by the pharmacy.
"Additionally, the pharmacy does not stock the Baxter heparin products , which were involved in both the Indianapolis and the LA incidents.
"After the most recent heparin incident at Cedar Sinai, our Clinical Pharmacy Coordinator Medication Safety, we decided to evaluate utilizing the bar code technology as an added safety measure. The NICU/Pharmacy Committee will review this at this Tuesday's meeting.
"Providing medications safely and effectively for our NICU population is of utmost importance to our pharmacy."
And, a bit more explanation:
"The Methodist Hospital NICU stocked heparin flush 10 unit/mL in 1 mL vial. The pharmacy technician mistakenly delivered heparin 10,000 unit/mL vials which are used for SC injections for DVT prophylaxis(there are also 20,000 unit/ml vials). This is what caused the 1000 x overdose. The news stories do not say that a pharmacist checked the vials before they before they were delivered. We require all medications be checked by a pharmacist.
"I am comfortable that this could not happen here. We purchase pre-made 3 mL heparin flush 10 unit/mL in 12 mL syringes. These syringes are blue and stored in a special section of the pharmacy designated for NICU only. The adult heparin flush syringes are 100 unit/mL and in a yellow syringe. These are stored with the main inventory far away from NICU stock."In July, we began stocking the NICU with premix heparin IV solutions. This enabled us to remove the heparin 1000 unit/mL 10 mL vial that had been stocked for nurses to prepare initial IV bags for UAC and UVC lines. The RN would add 500 units to the 1 liter bag of fluid.
"We removed the heparin 1000 unit/mL vial in July and the only heparin in Omnicell now is the heparin flush syringe. This was a safety quality initiative that the NICU/Pharmacy committee had started a couple of years ago and finally implemented it this July."
I just received a followup from Susan Young, clinical nurse specialist, in our NICU:
"The NICU/Pharmacy committee met today; pharmacists Karen Smethers and Steve Maynard joined us to look at other safety measures we could use in the NICU to prevent mis-dosing heparin. The NICU has only one concentration of heparin stored in Omnicell - the 10 unit/mL syringe. This syringe has a blue label. There is another syringe available through Pharmacy that is 100 units/mL. It has a yellow label.
"Omnicell has the ability to read barcodes. We decided to use this feature for heparin to provide a double check for the system. Pharmacy technicians load the heparin syringes into Omnicell. When they do this, they will barcode the heparin syringes. This will provide some safety, but will not ensure that all syringes are of the correct concentration because only one syringe can be scanned when filling the Omnicell bin. (To scan each syringe would require the technician to close the draw after each individually scanned syringe and re-enter Omnicell.)
"The second part of the safety will require the NICU nurse to scan the syringe when removing it. This will ensure that she has removed a syringe with the correct heparin concentration, in the chance that a syringe was incorrectly loaded in a batch. These added steps provide some added layers of safety.
"The NICU is moving ahead with implementation of POE. This will also help to prevent errors and overrides when we have a quicker way of sending order sets for medications to the Pharmacy. Admission of infants to the NICU is one time when we remove medications prior to them being overseen by Pharmacy. Umbilical lines require heparin, vitamin K and erythromycin are administered quickly. POE will help with this process. One system issue that interferes with a more rapid process is that infant medical record numbers are generated after an infant is born. The committee will be examining whether it is possible to start that process earlier so that medications that are needed immediately after birth would be ordered and authorized by Pharmacy, in some cases even prior to the birth of the infant. Working with Admitting is key to this part of the plan, and one that is recommended by Karen Smethers as a way to provide more Pharmacy oversight."
"Do you have thoughts to share on the preventable heparin error involving Dennis Quaid's twins in L.A.? What steps is BIDMC taking to proactively prevent that same error from occurring in your hospital?"
After consulting with our people, I posted this initial response, with the help of Greg Dumas, one of our pharmacists:
I asked our folks about the heparin question you raised. Here is part of the response from one of our pharmacists. As you can see, the staff is still working on other ideas.
"Please see the steps below that we put in place prior to the tragic September 2006 incident at Methodist Hospital in Indianapolis.
"1) Heparin Flush Syringes 10 unit/mL are stocked in the NICU Automated Dispensing Machine(ADM). These syringes are stored separately from adult heparin products in an area designated for "Neonate Use Only".
"2) All medications that are filled in the NICU ADM are checked by a pharmacist prior to delivery.
"3) All heparin containing intravenous fluids are prepared by the pharmacy.
"Additionally, the pharmacy does not stock the Baxter heparin products , which were involved in both the Indianapolis and the LA incidents.
"After the most recent heparin incident at Cedar Sinai, our Clinical Pharmacy Coordinator Medication Safety, we decided to evaluate utilizing the bar code technology as an added safety measure. The NICU/Pharmacy Committee will review this at this Tuesday's meeting.
"Providing medications safely and effectively for our NICU population is of utmost importance to our pharmacy."
And, a bit more explanation:
"The Methodist Hospital NICU stocked heparin flush 10 unit/mL in 1 mL vial. The pharmacy technician mistakenly delivered heparin 10,000 unit/mL vials which are used for SC injections for DVT prophylaxis(there are also 20,000 unit/ml vials). This is what caused the 1000 x overdose. The news stories do not say that a pharmacist checked the vials before they before they were delivered. We require all medications be checked by a pharmacist.
"I am comfortable that this could not happen here. We purchase pre-made 3 mL heparin flush 10 unit/mL in 12 mL syringes. These syringes are blue and stored in a special section of the pharmacy designated for NICU only. The adult heparin flush syringes are 100 unit/mL and in a yellow syringe. These are stored with the main inventory far away from NICU stock."In July, we began stocking the NICU with premix heparin IV solutions. This enabled us to remove the heparin 1000 unit/mL 10 mL vial that had been stocked for nurses to prepare initial IV bags for UAC and UVC lines. The RN would add 500 units to the 1 liter bag of fluid.
"We removed the heparin 1000 unit/mL vial in July and the only heparin in Omnicell now is the heparin flush syringe. This was a safety quality initiative that the NICU/Pharmacy committee had started a couple of years ago and finally implemented it this July."
I just received a followup from Susan Young, clinical nurse specialist, in our NICU:
"The NICU/Pharmacy committee met today; pharmacists Karen Smethers and Steve Maynard joined us to look at other safety measures we could use in the NICU to prevent mis-dosing heparin. The NICU has only one concentration of heparin stored in Omnicell - the 10 unit/mL syringe. This syringe has a blue label. There is another syringe available through Pharmacy that is 100 units/mL. It has a yellow label.
"Omnicell has the ability to read barcodes. We decided to use this feature for heparin to provide a double check for the system. Pharmacy technicians load the heparin syringes into Omnicell. When they do this, they will barcode the heparin syringes. This will provide some safety, but will not ensure that all syringes are of the correct concentration because only one syringe can be scanned when filling the Omnicell bin. (To scan each syringe would require the technician to close the draw after each individually scanned syringe and re-enter Omnicell.)
"The second part of the safety will require the NICU nurse to scan the syringe when removing it. This will ensure that she has removed a syringe with the correct heparin concentration, in the chance that a syringe was incorrectly loaded in a batch. These added steps provide some added layers of safety.
"The NICU is moving ahead with implementation of POE. This will also help to prevent errors and overrides when we have a quicker way of sending order sets for medications to the Pharmacy. Admission of infants to the NICU is one time when we remove medications prior to them being overseen by Pharmacy. Umbilical lines require heparin, vitamin K and erythromycin are administered quickly. POE will help with this process. One system issue that interferes with a more rapid process is that infant medical record numbers are generated after an infant is born. The committee will be examining whether it is possible to start that process earlier so that medications that are needed immediately after birth would be ordered and authorized by Pharmacy, in some cases even prior to the birth of the infant. Working with Admitting is key to this part of the plan, and one that is recommended by Karen Smethers as a way to provide more Pharmacy oversight."
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