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Two premature infants were killed and four other newborn''s lives were put at risk after they were given the wrong dose of heparin, an anti-coagulant drug, in the neonatal intensive care unit at Methodist Hospital, officials announced yesterday.
Two-day old Emmery Miller and five-day old D''myia Alexander are thought to have died from internal bleeding caused by a drug overdose of a commonly administered drug that prevents blood from clotting in tubes and intravenous needles.
However, the six preemies in the intensive care unit that were given heparin that day received a higher dosage that is typically prescribed for premature infants, leading to an accidental overdose.
What went wrong?
A preliminary investigation of the events found that a staff member, most likely in the pharmacy department, negligently placed a vial of a high concentrate of heparin in a drug cabinet in the neonatal unit.
Consequently, another staff member(s) removed the high dose vial from the cabinet and failed to double-check whether the vial matched the concentration amount listed on the drawer before administering the drug to the infants.
Six babies received an overdose, causing two deaths and putting four at risk of serious, life-threatening injury.
According to the president and chief executive officer at Methodist, Sam Odle, several staff members committed “procedural errors” that directly resulted in the deaths of the two infants.
The hospital will take action to prevent such mistakes from reoccurring and plans to contact the drug maker and advise the packaging be altered to more clearly differentiate between the various dosages.
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