More heparin overdoses, this time in Texas

Add at least 17 Texas infants to the number of children mistakenly given overdoses of heparin in the hospital. At least one of those infants died, and an autopsy is planned to determine whether the blood thinner played a role. Another is still in critical condition.

The problem reportedly occurred in the Christus Spohn Hospital South pharmacy, according to the Corpus Christi Caller-Times.

This may sound familiar to Los Angeles and Indianapolis residents. The newborn twins of actor Dennis Quaid made headlines across the country last year after an accidental overdose of heparin at Cedars-Sinai Medical Center in Los Angeles. They survived, but three infants died in 2006 after a similar mix-up at Methodist Hospital in Indianapolis.

The incidents received national attention. Quaid testified before the U.S. House Committee on Oversight and Government Reform about his family's experience, and he and his wife, Kimberly, created a nonprofit organization, the Quaid Foundation, to reduce human errors in medical care. Many news stories and analyses about both incidents followed.

And yet such errors keep happening.

As a 2006 Institute of Medicine report "Preventing Medication Errors" points out: "Medication errors are among the most common medical errors, harming at least 1.5 million people every year."

It's hard to see how patients, in this case their families, could have prevented these mix-ups. But there are some things patients can do to help protect themselves. Somewhat.

Here's a tip sheet from the federal Agency for Healthcare Research and Quality: 20 Tips to Help Prevent Medical Errors. It includes logical tips such as "When your doctor writes you a prescription, make sure you can read it. If you can't read your doctor's handwriting, your pharmacist might not be able to either." But perhaps most important: "Speak up if you have questions or concerns. You have a right to question anyone who is involved in your care." At the bottom are other links to online resources and reports, many of them quite good.

For an L.A. Times Health section look at the issue, check out a couple of articles produced in the wake of the Cedars-Sinai overdose: Patient, protect thyself and 'It's never just one thing' that leads to serious harm.

Also, as a bonus, here's the rather bland statement from the chief medical officer of the Christus Spohn Health System and, if you're curious about heparin in general, some understandable -- and useful --  information from Drugs.com.

-- Tami Dennis

Photo: Actor Dennis Quaid testifies before the U.S. House Committee on Oversight and Government Reform in May.

Credit: Shawn Thew / EPA

Comments

[Becca]

Anyone knows in the medical field that no matter how sick the Baby was that died from the over dose of heparin it was most likely the over dose of heparin that killed the baby. It just makes me so mad that the hospital can say they do not know what one it ws that killed the baby its illness or the over dose of heparin. I'm just sure there is more of this going on than anyhone of us knows in the hospitals today. Hospitals always want to pass the blame on.

[Bill]

Some of the blame could be put on the pharmaceutical companies for not making Heparin administration bottles different. I believe the bottles have color coded caps as well as having the concentration marked on the multiple-dose vials.

The lower concentration does are for flushing out intravenous lines while the higher concentrations are use therapeutically to prevent new clots forming in both stroke and heart attack victims.

Perhaps some nurses are color-blind as well as careless, but these two causes need to be investigated and solved.

A patient has no idea what is being injected into his intravenous line and we are at the mercy of incompetent healthcare professionals.

[Robyn]

When life hands you a lemon, make lemon-aide.

Doctors, pharmacists and the rest have insisted upon sequestration of our access to medicine. If in pain, one cannot buy morphine. If concerned about one's liver, one cannot order one's own labs, like an ALT or SGOT. Instead, physician/pharmacist/nurse arrangements have been legalized into a sort of debauched land of taboo and sly winking between medical professionals of all sorts to cover each other's butts and allow the control technologies that are the property of all civilization, not merely a select few gatekeepers who can each charge for a ride on the merry-go-'round.

Consequently, we all pay outrageously to have these good people "protect" us from ourselves. "Ah, it hurts!" I might say. "Indeed says the nurse! That will be $25.00, and then I might let you see a doctor."

"Well, well," remarks the well intentioned doctor. "I bet that does hurt! Here, take this to your local pharmacy...oh, by the way; that will be $250.00 if you please." For that matter, it will be the same price whether you agree or not.

The pharmacist then gets the prescription, which you hand deliver. Such luxury! "Hmm," speaks the pharmacist. "This is a little expensive, but I can have it for you in three hours. Come back then." For this inconvenience you might be charged any amount. Or you might be told to take a hike because the pharmacy thinks you look like an addict, or considers pain killers too much trouble to stock and dispense.

There was a time in the United States when it was considered everyone's prerogative to handle their own care. Now we are not merely dependent upon technical expertise of a doctor-consultant due to the complexity of medicine. Rather, we have been legislated into MANDATORY use of a huge and costly system to dispense medical care, a method that some of us do not want or need in many cases.

Let them do as they please. Then when they screw it up anyway, (psst…they will often do so, though far more often than they get caught) sue them within an inch of their lives. This is, after all, the American Way.

There is no liberty handed away for free. We all pay. Since medicine has managed to restrict itself to the control of this select few, they are responsible for the outcomes completely. Medicine men and women have the power, but balk at the responsibility frequently. Tough. Ain’t it still good for you too, doctor/nurse/pharmacist/hospital, when the money has to flow the other way? With great power comes great risk. Let the medical gatekeepers charge as they will, then let them also carry full responsibility for their outcomes. See medical care for the crap-shoot it really is. And then when things go astray, well, make a living off the misfortune the same way medical staff manage. Take them outside of their hallowed halls into those of American justice, and beat them senseless with the club you may now wield. This is your right, just as it was theirs’ to bargain health like a commodity.

I acknowledge that this is not convenient. A dead child is still a dead child, and a damaged body is still damaged. But for every medical order that results in litigation, a thousand go undiscovered, many times hidden by a conspiracy of secrecy and silence on the part of those who do the harm. It is only fitting that those who assume the power pay the piper now and then. Consolation is a bitter thing in the face of a death, but the system awaits you. Be served by it, and when not served make them pay you the second time around. Unfortunately there is no better relief.

They may well own the merry-go-'round, may well be free to charge as they wish. The natural corollary of this is that everyone who takes a ride gets to grab for the gold ring. Sometimes people will be hurt by falling off in their grasp for the free ride. I doubt that there will be any more injuries in this grasp than are harms caused to those who cannot afford to ride the medical merry-go-'round in the first place.

[Rebekka]

I'm not sure what all the regulations are for labeling drugs, but if the labels on the heparin bottles look so similar, couldn't hospitals put their own mark on a bottle to differentiate them? When a shipment comes in, have a nurse take a couple hours and mark all the labels of one of the types with a Sharpie. OR keep the higher doses in a totally different place than the lower doses so nurses have to make a conscious decision when they go get them. I bet the parents of the infants who are affected would think the hospital's extra effort was worth it.

[Lewis B. Sckolnick]

We need smarter medical staff from the top down.

[Suzanne Gentling]

Don't get sick and stay away from hospitals if you possibly can.

[Ajlouny]

I read more and more reports of the errors made with Haparin, why are the hospitals not making any move to preventing these errors from continually happening. It sad and scary that there have been no evidence of someone taking notice and making a change.