"To knowingly overdose an infant is unforgivable."
I understood all of the points you were making till you bacame a bit ooverzelous with the above statement. Next time use a bit more sense and less drama to explain a serious situation and implication. If your job is to report...be 100% accurate with all of your statements. After all, is that not what we expected from these nurses and pharmacists...ACCURACY. Be responsable!

My wife is one of "these nurses". Its not the nurses fault, its the phamacy. Heparin is a one to one mixture with water which is done in the pharmacy. The nurses are not to blame here.

Nurses are required to double check medications before administering the medications to patients. The out right awareness and knowledge of past issues with Heparin and baby overdoses should have alerted hospital staff to take extra caution regarding infants and Heparin and the fatal results that overdosing can bring.

If this story becomes a legal case, you can bet that a memo exists on Heparin that was passed on to the medical team at Spohn. Especially after the tragic national news story of actor Denis Quaid's children being overdosed in California last year.

Maybe someone missed the memo. Time will tell.

They didn't 'knowingly' overdose. Clearly someone was negligent, but I certainly hope you aren't implying that someone meant for this to happen.

Bob, you are mistaken in calling Heparin "controversial". The drug itself is older than the FDA. It is highly accepted in the medical community as an effective agent for the treatment of several diseases and afflictions.

Amanda,

To clear the air, my comment that they were given Heparin on purpose was just that. They were given Heparin. I am not saying they intentionally wanted to overdose a baby. I am saying that a medical standard of care was violated when they were overdosed with Heparin.

Sebastian,

While its true the drug has been around. There is no denying the controversy the drug has created with labeling issues, and production of the drug issues dealing with China just to name a few, etc....

The drug company has addressed the issue in making a label change for different doses. The facts are not clear as to how the mix up in the pharmacy occurred at Spohn, but no doubt controversy exists regarding the overdosing of Heparin in infants. Just do a google search on Heparin and you can easily see the controversy at work.

Bob,

Again, my wife one of these Spohn nurses in question. Understand that by the time the Heparin gets to the nurse to be administered it is ALREADY in mixed form which is where the error occured. The nurses are not at fault here, the pharmacy is. If the nurse had given the wrong dosage, meaning 50cc when 75cc were the directions, then okay, blame the nurse. If the nurse had administered Codone when they were supposed to give Advil, then okay, blame the nurse. But when the nurse gives the required amonut of Heparin from a bottle that is labeled Heparin, then you can not fault them. In this case, they were checked accordingly by the nurses.

This is a perfect example of a system error. I, too am a nurse in the Spohn system, and things like this can occur. It's not a common error, but we as nurses are the last check in a system before medication administration; this is true. Heparin comes in many dose concentrations 1:1000, 1:10000, 1:1000000 and similar labeling from manufacturers and all it takes is a mistake...which all humans are capable of. The actions of the hospital are correct in not being strictly punitive. The error has been discovered, and now it is known. Now it is time to fix it. There is no blame on any one individual, as these pre-mixed pharmacy preparations may be labeled appropriately, and we, as nurses have only that label to rely on. We are not there when it is prepared. If it states a certain concentration, we have to trust that it was mixed appropriately and administer it.

As a member of the pharmacy profession, I am sick and tired of pharmacy always being to blame for medication errors. Also as the medication error reporting manager in my facility, I see so many errors being made by nurses, physicians and even the patient themselves. I am not making light of this tragic situation by trying to justify that pharmacy personnel are not always to blame; many times pharmacy is just one of the many entities that unfortunately are frequently the culprit for medication error. Let's not pass judgment on the individuals involved; let the investigations conclude and the rest of the healthcare community be prepared to reform and revise current practices. Let this situation be a reminder to all health care professionals that medication errors do occur and it is our responsibility to make sure that we all are in a constant frame of mind to perform our jobs with the patient's safety being top priority.

I think that folks fail to realize that Level 3 NICU is no joke. We are talking about very sick babys here. The child that died had a serrious viral infection as did the twin sibling (Meningitus to be exact). Whos to say the error played any part in these deaths?

The problem here is that everyone wants to point the finger to everyone and anyone. The bigger picture is that the employer which is christius spohn is totally responsible for their own employees actions. Im sure that they give adequate training to prevent issues like this from happening. The problem that i have is that these are human beings that they as a hospital and they as employees should take very serious when the patient is under their care. so christius take the responsibility on your employees cause afterall they are all on your payroll.

"In an effort to spin the story, hospital officials were quick to point out that all these babies in the neonatal unit were seriously ill, possibly implying that the deceased infant's health, may have played a role in the death."

Hello Bob, A NICU is where a baby goes when they are ill!!! I had twin nieces in the NICU(at spohn south)that were born at 35 weeks as well. Guess what? They were extremely ill with max support! I can not believe that you would say such a thing in this article that the infants health may have played a role. Of course it did! They were in there for a reason!

"To knowingly overdose an infant is unforgivable"

You think that this was knowingly done! Who are you to have the right to judge anybody!!! You dont! Unless you work in the NICU or Pharmacy you have no right to talk about this issue! Plus, you need to get all your facts right before you go on the internet and start accusing!

Dear Unknown/Ghost Poster,

They were given the Heparin overdose and that's a fact!!!

Since the family has hired an attorney, the TRUE judge will now be a South Texas Jury.

How come you failed to mention in your article that according to the neonatologist and according to the autopsy it was related to the heparin.

Im so sorry typo! It was not related to the heparin.