Human Error Responsible for Preemie Deaths in Indianapolis

In the news today was the story of 2 preemie deaths due to human error. I am deeply saddened (and scared) by this story.

Heparin. If you are in the medical community you have most definitely heard of heparin if not prescribed it or administered it at some point in your career. If you are not familar, Heparin is a "blood thinning" or anticoagulant drug that helps prevent clot formation. Heparin comes in different concentrations for infants and adults.
Typically a doctor would prescribe it and the nurse would go to the "Suremed/pyxis" (it is called something different in different hospitals, but essentially it is a locked computerized drug system), which is stocked by pharmacy, and retrieve a vial of heparin. Following the physicians orders and her own calculations to double check, the nurse would draw up the amount necessary and administer.
Except in the case in Minnesota, the pharmacy had the wrong concentration of heparin stocked in the nicu "suremed." The health care providers that administered the heparin to several premature infants did not pick up on the fact that the concentration was incorrect and essentially overdosed these children on anticoag medication. In the neonatal and pediatric setting, it is required (at least in our unit and I am assuming in most places if not everywhere) to double check certain medications with two registered nurses, heparin included. So far, two babes have died and others are still considered in critical condition.
In the field that we are in, human error is inevitable but how could something could have gone so wrong? First, an experienced pharmacist made a mistake by placing the wrong concentration of heparin into the suremed. Do they not have doubles checks as we nurses have to do? Second, the nurses involved are responsible for checking (and double checking with another RN) all drugs that are administered.
Things get so routine that mistakes are made and lives are changed for it.


As a new nicu nurse, I have this intense fear that I am going to royally screw something up and get called at home with that scary phone call that I have done something horrible (unknowingly) and bad things have happened as result. This story is terrifying to me as a new nurse and I have several questions about this fatal medication error in Minnesota and how something like this could have happened. For me, it opened my eyes *yet again* to the fact that an error can turn my life upside down and I could lose my newly earned license. It reconfirms that idea that I need 8 hrs of sleep before work and that I need to stay focused while at work (are you rested and in the moment at work???) In other words, the idea of making a fatal mistake scares the sh*t out of me.