15,000 units of heparin was given, instead of 1,500. Always write out “units” when prescribing, rather than a “u” after the dose.
Related posts:
- Sam Blackman on poor physician handwriting
- Physician handwriting and prejudice
- Poor reimbursement leads to physician shortages
- How poor physician communication leads to medical mistakes
- "Hold Your Wee for a Wii": Water intoxication leads to a contestant’s death
- "Single-payer medicine inevitably leads to shortages, suffering and death"
- Pig intestines and heparin
KevinMD.com on Facebook
{ 3 comments }
Inadequately trained nurses also contributed heavily. Since the dose given is several times the typical adult dose, some alarm bells should have gone off in the nurse’s head. The thought should occur “I’ve never given this much heparin ever, and I’m about to give it to an infant?”
The source for the error started with the physician, the error took life when the nurse misread the order, but it took probably several others to uncritically execute the error. Health system stretched tight on staffing have more holes in a system adequately staffed with experienced and unhurried people.
Any time a nurse or physician has to open multiple vials of any medication for a single patient, they should look carefully at the order and re-evaluate the situation. The recently posted phenergan overdose is another example.
WTF is happening to people?
I totally agree with Gasman.
Comments on this entry are closed.