Medical technology can be a mixed blessing. Just ask the parents of Thursday Dawn Jeffries, the third baby to die from an overdose at Methodist Hospital in Indianapolis in less than a week. The cause of death for all three infants was an overdose of Heparin, an anti-coagulant medication used on infants.
While it is devastating when such errors occur, it doesn’t take much for such a thing to happen in medical science. Ironically, the same drugs that can save lives when administered correctly can kill when administered in error.
Heparin is a concentrated drug, much like insulin and morphine, and thus a very small error can cause a devastating result. Six infants at the hospital were given adult doses of the drug, which is more than a thousand times the amount they should have received. Three have died and three others are listed in critical but stable condition, thanks to the hospital staff who caught the error and began treating the infants.
The hospital has offered to pay for funeral expenses and financial restitution to the families. Of course, money is no substitute for a life, and the hospital and parents of the deceased infants undoubtedly know that.
However, the error that caused such an abominable result was not egregious. According to the Indianapolis Star, “A pharmacy technician with 25 years of experience accidentally delivered vials of Heparin in adult concentrations to the neonatal intensive care unit.”
The vials, which contained an adult dosage of 10,000 doses per milliliter, looked almost identical to vials containing the 10 doses per milliliter required for infants. Nurses simply chose incorrectly and didn’t check the dosage on the similar-looking bottles.
Needless to say, the hospital has taken steps to ensure such a problem won’t happen again. A mass re-education of drug dosage procedures is being administered to nursing staff, and new procedures – such as requiring two nurses to validate doses – are being adopted. Still, this is probably small cause for celebration for the parents of the deceased.
As hard as it may be to swallow one’s anger, the hospital staff that administered the drug need not be fired. Everyone makes mistakes at work. If a technician with a quarter-century of experience could make such an error, any hospital worker could. Likewise, Heparin need not be attacked. It’s an effective drug that has saved the lives of many infants and adults. Heparin is just dangerous and needs to be handled with extreme caution. Such are the costs and benefits of technology: Millions may benefit or have their lives saved by the fruits of technology, but small mistakes can lead to catastrophe.