October 2, 2006 |

Monday Accident & Lessons Learned: Medical Mistake: Premature infants receive adult doses of Heparin

 Cnn 2006 Us 09 17 Premature.Infants.Ap Story.Hospital.Ap

(Methodist Hospital in Indianapolis)

Again, medical errors are in the news.

At Methodist Hospital, six premature infants were given the adult dose of a blood thinning medication (Heparin).

What did the news have to say?

CNN:

http://www.cnn.com/2006/US/09/17/premature.infants.ap/index.html

Associated Press:

http://seattlepi.nwsource.com/health/1500AP_Preemie_Deaths.html

USA Today:

http://www.usatoday.com/news/nation/2006-09-20-baby-deaths_x.htm?csp=34

Local TV / Good Morning America:

http://www.theindychannel.com/news/9884927/detail.html

To make things even sadder, the hospital missed the chance to learn from a previous (2001) incident where two infants were given adult doses of Heparine and survived. The hospital had a chance to use advanced root cause analysis and develop effective corrective actions … but they missed it. What a shame.

I would guess that we aren’t too far from seeing such mistakes being treated as criminal negligence. People – nurses and even hospital administrators – could be facing jail time for errors that are preventable. I’m NOT saying this is a GOOD way to prevent future Sentinel Events. But when people get fed up with needless deaths, criminal prosecution may seem to them to be a just result and a way to get the attention of healthcare industry executives.

What are the lessons learned from this tragic event? Here is a link to some ideas from a professional society (the American Society of Health-System Pharmacists):

http://www.ashp.org/emplibrary/Med%20Error%20Member%20Update.pdf

These types of errors are why we plan a special track at the TapRooT® Summit devoted to stopping medical errors. For the schedule for this track at the Summit, click here, and then click on the Medical Error Reduction Best Practices button in the Display Selected Track box on the web page.

We can stop medical errors. These types of errors are preventable.

Root cause analysis of Sentinel Events like this one can contribute to our learning. Every hospital should have several root cause analysis experts trained in TapRooT®.

But it would be even better if hospitals used best practices and proactive improvement methods to stop medical errors BEFORE Sentinel Events happen.

The TapRooT® Summit is an excellent place to learn best practices and proactive tools from the hospital industry and from other industries (nuclear, aerospace, utilities, mining, manufacturing, transportation, …). If you are responsible for root cause analysis, quality improvement, human performance improvement, or risk management at a hospital, why haven’t you attended:

– A TapRooT® Course

– The TapRooT® Summit.

Don’t wait for a newsworthy Sentinel Evenet to start learning. You need this information to help you improve your hospital’s performance. Get the budget in place and the travel authorized to attend the TapRooT® Summit and a 2-Day TapRooT® Course on On April 22-28, 2007. When you attend both a TapRooT® 2-Day Course and the TapRooT® Summit you will SAVE $200! Click here to register.

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