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“In 2007 Dennis Quad’s infant twin babies were admitted to Cedars-Sinai Hospital in Los Angeles, California, to be treated for a staph infection (60 Minutes, 2014). During their hospitalization the twins were prescribed 10 units of HEP-LOCK, which is a pediatric blood thinner used to flush out IV lines and prevent blood clots. However, instead of receiving HEP-LOCK they were given the adult version Heparin. The adult dose of Heparin consists of 1,000 times higher of a dose than the twins were prescribed. The medications were both stored in the same size bottle, both with light blue labeling. The result of this overdose caused the twins blood to have the consistency of water, and caused them to bleed out from sites that they were pricked with needles. Upon recognition of the overdose, the twins were administered an antidote and later stabilized. The parents of the twins were not notified of the incident of overdose until a day later. This incident could have been avoided with proper preventative measures in place. The drug heparin, which was used by mistake on the twins, went through three different sets of health care professionals unnoticed. The first person, being the individual who placed the adult version of HEP-LOCK in a drawer on a pediatric unit. The second person would bring it from the medication drawer to the location where it would be administered, and the third person in the chain would have administered the drug. Here are three instances where healthcare professionals did not check the drug and notice the mistake. There should be a quality control process implemented along the lines of a medication checklist, to ensure medication errors are prevented. The hospital should also have regular audits of drugs to ensure they are being stores properly, stored in the proper location and expiration. There had also been previous medicine administration error of the same kind involving Heparin at a different hospital in another state where six babies died from confusing the two drugs. At this point the manufacturer Baxter Healthcare Corporation, which provides half the supply of heparin in the United States (Tanne, 2008), sent out a memorandum alert and redesigned the bottle. Despite the fact that they changed the labeling, they did not remove existing stock from hospitals. The medication that was administered to the Quad twins was from the existing stock (60 Minutes, 2014). Baxter healthcare and the hospital should have been more proactive and removed all existing stock to prevent any medication errors from occurring.
There are multiple issues surrounding medical administration errors in this scenario. To ensure patient safety during drug administration individuals must abide by the seven rights of drug administration. In the situation of the overdose of the twins two of the seven rights were not executed correctly: right drug and right dose. Right drug begins with checking the order from the doctor to ensure it is correct. Each time the drug is dispensed , the label must be checked three times during its preparation to confirm the right drug, right dose, and right strength. The first check is performed when the drug leaves the storage area, the second when removing the medication from the container and the third when it is returned to the storage area of just before administration (Moini, 2018). Right dose ensures proper dosage is administered, if calculations are needed they must be converted. The conversion should always be double checked by another approved administrator. Many health care facilities require heparin to be double checked as well (Moini, 2018). ”
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“Medication errors can be debilitating and even fatal. A simple error can have big consequences as such was the case with Dennis Quaid and his twin new-born sons who received not only one incorrect dose of heparin, but multiple. The nurse on duty had grab the wrong type of medication and delivered it without knowing it. The Quaid’s later settled out of court but the children nearly died. As nursing students, we are expected to put our patient safety first and foremost above all else. As a previous LPN student, knowing how important it is to make sure that you have the correct medication first, is key to making sure that you prevent medication errors. Some medications come in the same bottle but of a different dose so it is important to make sure that you have selected the correct medication for the correct patient. In reference to the Quaid’s medication error of their children, the first error came when the nurse did not check the label of the medication and the dosage. Although the medication for the children was very similar to an adult dosage bottle, the nurse should have double-checked the bottle by reading the information and dosage on the face of the bottle. The second mistake was that the nurse did not verify the medication with another nurse to confirm their medication check along with their medication dosage– for pediatric medications, this is required and should always be practiced. For this situation, Baxter Pharmaceuticals recalled the current medication after 3 more fatalities happened after the Quaids’ twins almost nearly died; the company then changed their packaging of the infant-dosage of Hep-lock to have a sealed wrapper on the top of the bottle notifying the nurse or staff that the dose being given is a pediatric dose (hep-lock) and not for adults (heparin) or vice versa. This video showed me the importance of making sure that you have checked the 5 rights of medication administration and the effect that an error can have on a family or patient. Drug safety starts with the Doctor but it finishes with the nurse (Tariq, 2020). When we are going to be administering a medication to a patient when we are on our own, we must make sure that we have the right patient, the right drug, the right route, the route time, and the right documentation. But as a student, we are never to administer medication of any kind without an instructor present and observing. When we as the nurse are administering medications of any kind, we must also make sure that we are considering the reactions that the patient might have by checking the MAR of the correct patient, this is crucial in helping prevent medication errors and adverse reactions. Researching topics such as medication errors helps in my understanding of the prevalence and severity of medication errors and increases my awareness of how to prevent these mistakes from happening. Research helps us learn and be proactive to a problem before it happens. “