I read that last night. It's just awful.

This happened earlier this year to another newborn baby which died. What suprised me the most is that there are 2 bottles. One is the adult dose that the hospital accidentally has given to these newborns and the newborn dose. The bottles are identical. At what point does the pharmaceutical company step up and change the packaging on the bottles. Im not saying the hospital isnt to blame. But i think the pharmaceutical companys could easily prevent these tragedys by just changing the bottles.

The bottles have the dosage printed on it.
Nurses should be able to read.

This is horrible. I feel so bad for them.

It's outrageous that this happened.

And this was in the article:

The Bush administration in August announced that Medicare no longer would pay for preventable hospital errors including injuries and infections.

It never ceases to amaze me the mistakes that happen in hospitals, so many of which can be avoided. I know we're all human and mistakes do happen, so we have to pro-active and ask questions whenever given anything or being taken to surgery. Stop them from administering anything until they answer your questions.

Seven doctors within 4 months made the same dumb mistake on a friend (rest her soul) of mine. She lost her leg as a result and got pennies from the lawsuit. She tried to tell one of the doctors (the 5th doctor and only female) what was really wrong, but the dumb broad told her "That's why I'm the doctor and you're not." All she could do was apologize later, which does no one any good at all. I hear of this type of thing all the time.

I think there's no excuse for that kind of hospital carelessness. I assumed that they'd be extra careful with treatments of children, especially newborns. I hope the twins recover.

Why would an Adult strength bottle of the stuff be in a newborn nursery anyway?
They should make the bottle different colors or something and add larger print. I can't read some dose recommendations on my Advil bottle, even with my glasses on.
I hope they're okay too. Mistakes happen yes, but this one shouldn't have.
Leslie

It actually didn't surprise me. When DGD was in hospital with Menengitis and they were removing the respirator, they gave her an adult dose of something that stopped her heart. Luckily they were able to start it up immediatly, but the menengitis didn't kill her, a nurse almost did!

Vickey-MN

This happened at Cedars Sinai in Los Angeles. It is supposed to be one of the best in the country. I wonder if the nurse was fired?

The nurse is ultimately responsible for reading the vial but the pharmacist was the first person to handle the vial. They sent the vial to the pediatric department I'm guessing and the nurse assumed it was correct. Nurses are taught to read every drug because mistakes do happen.

I don't know what really happened but the RN NEEDS to know her drugs and read them everytime. I recall having two or three nurses reading the label when infants where involved, back when I was an LPN (I didn't administer IV drugs though). No one wants to make a mistake, especially with an infant.
I hope they are OK too. They must not be full term and have complications to be getting heparin.

As a nurse who has looked after babies in an NICU, I can see this happening. Those vials of heparin are very small(about an inch long) and the writing is so very tiny. It would be really easy to miss an extra zero when reading the vial. It is also very easy to draw up the wrong amount since the amount of the heparin drug you actually give is very very small. A new nurse unfamiliar with neonates and their small doses might miss this, since the dose you draw up for an IV bag is sooooooooo very small. At our hospital we double checked all meds and co-signed with another RN to prevent such errors from happening. I'm glad they recognized the error and that there is an antidote for it.

Can you imagine working 12 hour shifts, missing breaks or eating on the run. Count travelling and report time and your shift is an easy 14 hours. Try doing that for 3-4 days in a row and you will see why mistakes are made. NICU nurses are generally extremely busy and overworked. Often I would work a whole shift with maybe one or two 15 minute breaks. I'm actually surprised that there aren't more errors. Studies have proven that fewer errors were made when nurses worked 8 hour shifts. Yet 12 hour shifts are now the normal shifts, in fact many hospitals have no 8 hour shifts except in clinics.

Linda, I'm sure Heather, Kathleen, or others who are/were nurses can tell you better than I can, but I've never known nurses or doctors to be fired over mistakes. I'd really hope eventually someone is fired after making many mistakes. All I heard was it goes in their file, and they have to answer to the board.

Toni, there's a video in the link that said the babies were getting Heparin mainly to prevent clotting at the IV site. Or something like that.

Susan, Bush and his administration has advocated everything likely and possible for patients to be screwed over after getting screwed over.

We successfully sued a hospital and nurses for multiple mistakes that almost killed DH in the OR and CCU - in a large University hospital.

The nurse in the CCU (mistake that started it all) did not lose his job (it was a BSN).

I really don't know that firing is the answer here since if what Heather is saying is true, it sounds like they need to change the packaging somehow. I truly believe that nurses and for that matter a lot of health care professionals, are very overworked and it seems that it will only get worse. Now that's scary!

It's awful when those things happen and I have to agree with Heather, long hours, working multiple days in a row. Do you know I just got home? I left my house at 6:40 this morning (I was running late, usually leave around 6:30, unless I know I'm going to be charge then I leave at 6 am). I was swamped today, multiple discharges and admissions. I stayed a half hour late and made it home around 9:20 pm.

A few weeks ago I worked 7 out of 9 days in a row. The 2 days off I had weren't together. I was so exhausted by the last day that I ended up crying over a patient's complaint with "us" just before I went to give report. I should be in bed because I have to get up at 5 am and do it all over again, but I need to relax before I go.

I feel badly for the babies and parents but also feel bad for the nurse. She must feel horrible.

I saw a picture of the vials on TV. Their vials are different from the ones we had. I'm sure the nurse feels absolutely horrible. We all feel terrible when we make a mistake but we are human. Tired, exhausted humans at that. I was always paranoid about making errors and I do have to thank our system of double checking because there were a few times when we caught each other's mistakes. It is so easy to do especially when you are overworked and rushing.

Administration does keep track of drug errors, incident reports etc. Here in Ontario, if a nurse gets a poor track record, she can be brought before the College of Nurses for a trial to see if she will keep her license or not. If a nurse is fired from a hospital, then the hospital has to report that nurse to the College.

I had to laugh about something on TV tonight. They were talking about medical staff not doing proper handwashing. They showed that a proper handwash takes 2 minutes to complete and that nurses wash their hands 20-30 times an hour. HELLO! This doesn't compute too well with me.....the nurse could then be washing her hands the whole hour and nothing would get done! Thank goodness for having the alcohol gelly disinfectants but they are also very drying on hands, and once your hands get cracked they can harbour bacteria as well.

I really wonder if the public appreciate how hard nurses work. Yes, the error was careless and shouldn't have happened. I can appreciate why it happened having worked in a very busy NICU. The hospital were the twins were is probably just as busy or busier.

Heather and Kathleen, I sympathize with you. Truly I do. But I really think you're singing to the peanut gallery. Because I know and communicate with you, I feel bad that you feel overworked. However, I/we are not the ones to say this to. "I'm sorry" coming from me cannot help you in any way whatsoever, and "I'm sorry" coming from you surely cannot help me, these twins, they who lose limbs and quality of life, or they who die. Everyone with half a heart feels awful when they make a mistake that affects the lives and well being of others, but "I'm sorry" means nothing in the end. What can "I'm sorry" do?

It seems to me you two nurses, and therefore every other nurse, have identified at least part of the problem. And you all did so long before this incident with the twins. So, my question is why nothing has been or is being done about it. All hospitals know this to be a problem and have known for many, many years. It just tells me we are all expendable to them. Another patient lost, another patient maimed, and they go on business as usual. People don't go to the hospital looking for a lawsuit. They go to be healed and totally put their trust into what they consider capable hands. "I was tired" is not an acceptable excuse when something goes horribly wrong. Also, I know many nurses work doubles and should not be allowed if they are already so overworked.

Not trying to offend your good sense bestlawn but the nurse shortage has been going on for some time. They are overworked, understaffed, and its true, the nurses are still human and will on rare occasion make a mistake, usually not deadly but it does happen. Also nurses go on doctors orders and can make basic care decision on their own or with guidance from a superior. There are many safety guidelines to follow but it can not totally cover human errors. How many people can say they never make a mistake? Constant mistakes will call for termination but who's taking over? Sometimes NO ONE! More patients per nurse until a NEW employee, who doesn't know the ropes and will in time make a mistake. What a stressful job to have, knowing that any miscalculation could be the end of your job. Lots of jobs there is that opportunity to "do it over" but not so often in nursing. I used to work the 12 hour shift that really ment 13 or 14 hour days, Often 3 days in a row. Always on the go, charting, eating standing up in 3 minute increments even though we were suppose to have a 30 min lunch. Somedays our head nurse was so frazzled she would be sweating through her clothes. I'd hate to have that job.

I can understand patients and their families wanting perfection and complete healing but that is way to idealistic to expect at every given moment. Burn out is a major problem for nurses. They are not allowed to make a mistake, they have to be in 3 rooms at the same time, the doc wants to talk, respiratory is calling, therapy is coming, its time for meals or baths, visitors are in the room, its finally time to eat after 6 hours but there is no back up for a while, oh and did I mention they aren't allow to make a mistake and the guilt that comes with it if they do, weighs heavy on the mind. \

So yes its true if I were Mrs. Quiad, I'd be angry, really angry, but knowing how the media reports, and knowing what has been my hospital experiences I'm not going to pummel A nurse that can not do much more than say, I'm sorry. Its a tragedy when something like this happens and I'm fairly certain if this nurse doesn't pay with her job, she will pay with it on her conscience the rest of her days.

No offense at all. All three of you make perfectly good sense. I appreciate a better understanding of your job and sympathize with you. Nothing else I said was to negate that, only point out you're saying it to the wrong people since we here can't do anything. I think it's up to your union and possibly even government regulation to prohibit doctors and nurses from working more than x number hours per week. I guess that poses a catch 22 since hospitals are understaffed as you say, and it would also increase costs exponentially. I am not clever enough to invent a solution. That's why you're talking to the wrong people. But, I cannot agree mistakes are so rare. I venture to guess everyone on this board knows of at least one. That is an awful lot, and something has to be done by those much more talented than I am, by those who work in and give their all to an incredibly fallible system, and by those who never want to have to pay for the rest of their days.

And let me to say this, too. Although you're trying to tell us, there are not enough paragraphs or pages to really give us the clue of what you go through every day. You can't tell us how many smiles you've shared nor how many tears you've shed. I know I cannot imagine the rewards and disappointments all at the same time. I appreciate you, as I'm sure your patients do. Good days, bad days - you're entitled to them like everyone. There's no one on this earth to say they never made a mistake.

Speaking of mistakes, I really feel Bush got it all wrong to advocate reform the way he did. I think a better idea would have been to limit awards based on error, as opposed to all awards based on incident. My friend's experience I described above was an example of gross negligence, so she should not have been limited. Because people do make mistakes, then those awards should be limited instead.

Gosh I wish I could get to sleep. LOL

In top hospitals, nurses in critical care units are BSNs, specialists in that area...especially neonatal. The patient load is also minimal...2 or 3 patients.

Yes, mistakes happen on general floors...that's why a person should NEVER allow any medication to be given to them without knowing what it is and the prescribed dosage. It's only protecting yourself.

But children, people in CCUs cannot ask, cannot protect themselves...and that higher level of responsibility is accepted by those who work in those units.

To say stuff happens, is a poor excuse for gross neglegence. If a nurse in a CCU can't read fine print...then they need to get new glasses or transfer out of there.

Sometimes a very simple change can make a world of difference. A small example was many years ago when I worked at a large theater in Toronto that shows plays, like Broadway in New York. Every month we had to mail out tickets for the upcoming play to about 100,000 subscribers. The remaining 10,000 or so seats had tickets printed up each month for sale to the public at our Box Office. On my first day of work, we had to hand stamp (we're talking decades ago) 'Subscription' on the back of the 100,000 tickets we mailed out. But I noticed the remaining 10,000 tickets that we brought over to the Box Office were blank on the back. I asked my manager why and she said it was to differentiate them for auditing purposes.

I blurted out "Gee, wouldn't it be easier to just stamp 'Public' on the other 10,000?" She looked at me and said "I never thought of that, I'll bring it to the boss" and after 30 years the method changed almost immediately. We weren't dealing with life changing situations, just time and money, but that simple change saved 10 times the manpower and ten times the amount of ink we used. Now I was a just a typical 20 year old at the time who only stumbled across a great solution by asking an innocent question.

With patients lives on the line, there simply must be a better solution to the problem of confusing medication, at least in regard to the labels on the bottles. Obviously there aren't enough colours in the rainbow to make each different medication bottle look totally unlike another. But perhaps manufacturers could differentiate between pediatric and adult medications by colour coding the bottles.

So if Heparin for example might have a blue or green square of colour right under the name, the rest of the entire background colour on the label could be white for the adult bottle or vial and pale pink for the pediatric one.

Doublechecking obviously still has to occur to not misread the dose. But at least with 2 different background colours for adults and children, the staff will know which they're handling before they even begin to read the words. Whatever is done, I hope they find a better way to distinguish medications to lessen the risk factor for those who are trying to save lives, not take them.

Monica, in NICU's many nurses are not BSN's and frankly some of the better nurses are ones with diplomas. Experience is far more important than those just graduating with a nursing degree. Frankly those graduating are not used to heavy workloads for one thing. 2 or 3 patients in an NICU can be a very stressful and a very heavy assignment. Imagine having one critically ill baby on a ventilator, with meds keeping blood pressure up, antibiotics, bloodwork, starting IV's, checking all IV sites, and sterile procedures to do, vital signs to watch every few minutes, alarms going off constantly as mucus plugs the breathing tube.....and then having a "stable" surgical baby who is hungry because he is not being fed and screaming blue murder, on antibiotics, needs dressing changes, all IV lines need changing and there are 4 of them connected to this surgical little one, surgeons wanting bloodwork, and yes the nurse is responsible for checking the results of all bloodwork and calling the doctors if anything abnormal....oh and I forgot....the other nurse in the room is on break and there are her babies you are responsible for and her one baby's parents are demanding attention and want second opinions from her that they can "secretly" ask when their nurse is out of the room. I could go on and on.

WHEW, that is the life of an NICU nurse.

Yes errors should not happen. Nurses are trained to be careful. But as a nurse I can tell you that we do the very best that we humanly can. We do care for our patients, if something goes wrong we are heartbroken and we live with the guilt for the rest of our lives. We truely do care. Few nurses make it to 65, the age of retirement if they are working in an active setting with great responsibility. Shiftwork cuts our life shorter than the average person, we are prone to more life threatening illness like cancer because of our lifestyles.

I do understand your anger at what happened with your DH. Errors shouldn't happen where human lives are concerned. It is unfortunate that humans aren't perfect. We all make mistakes.

Yes nurses need to be able to read the fine print of a bottle and if they can't they need new glasses, or to retire gracefully. I often felt that nurses should be able to retire earlier than 65. In fact in our hospital, nurses were given the option of retiring early periodically and many took the chance. Transferring to a less stressful job is often hard to do because the "cushy" jobs of say a nurse in a quiet doctor's office are few and far between.

The nursing shortage is likely to get much worse. Nurses are underpaid for what they do. There are so many other fields of work for women these days that are easier and far better paying. Burn out is real. Maternity leaves are longer, more nurses are opting to work part time. I don't think as many are entering the nursing field. I laugh because our Prime Minister is "trying" to persuade nurses to stay longer in nursing by asking the hospitals to give older nurses less heavy duties. Being understaffed, that isn't going to happen long enough to persuade a nurse to stay. He is dreaming.

Heather, here in the US, top urban hospitals do employ only BSNs in CC units...and the pay is not poor...that's why so many RNs around here are talking courses to get their BSN.
A graduating BSN can start well over 50K a year...I have 3 nieces who can attest to that. Hospitals also offer signing bonuses of many thousands to BSNs who will sign contracts.

Maybe things are different in Canada.

Although hospitals prefer BSN's, there are a lot of diploma nurses and we are still training diploma nurses. There are a lot taking courses as well to get it. Our starting salary is not as high, in fact, I often wonder why anyone would want to be a nurse, when waitressing with tips in fancy restaurants can give you the same amount of money without the responsibility. Or teaching jobs can give you far better time off for the same amount of money.
We don't have signing bonuses that I know of, but it is a few years now since I have nursed so that may have changed. Nurses are given at least a 3-6 month orientation in our NICU before they are left to their own devices. They need it as there is so very much to learn that isn't covered in the BSN course. Many move on after a year because they feel the stress is too much in an NICU.

Nurses are well paid here too. I know of nurses who get $38 to $40 per hour..before shift bonuses etc.

My mom that i lost 2 years ago, was in a hospital, for swelling in her legs, and she received diuretics from an IV, came down with a really bad sore throat, never once did the dr. check her throat, he released her from the hospital on a Friday, I found her in bed the next morning, and she went into a coma, right after i found her, and by the next Friday she was gone. She contracted a staph infection, that turned septic.
Its very hard for me to trust the medical field now.

Canada. America. Timbuktoo.

RN. BSN. LPN. Aid.

It doesn't mattter! People are human and mistakes happen. I've also been affected by a medical mistake that cost the life of one of my loved ones. But I can't change that, and I don't see any need to be bitter and carry a grudge against everyone who works in medicine.

The babies in this case survived and will likely have no side effects. I choose to see this as an event that was "meant to happen" - and becauses it has been so highly publicized, it may well result in some changes that can help prevent it from happening again.

I'll get off my high horse now... I just grow weary of having people who work so hard to save lives continually get beat up.

Thirty to Forty dollars an hour is nothing compared to what plumbers, electricians, locksmiths, carpenters, landscapers, webmasters, computer techies make. Even the fellow that built our pond charged $75. an hour. Many get paid under the table so that they don't even have to pay taxes. Compare our education and responsibility. I can't remember my exact salary when I had to leave nursing with cancer 5 years ago but it wasn't as high as forty dollars and I was at the maximum level allowed with 32 years experience. I must look up an old pay slip. Chemo brain has me forgetting such details.

Better labelling on bottles does help. I particularly remember one case where a heavy duty drug was in the same shaped and coloured bottle as a standard vitamin. It didn't happen on my floor but a number of the babies became really sick and had to come to my unit due to the error. Changes were made in labelling and it never happened again. There certainly are cases where good can come out of mistakes, and I bet this is one time where there will be a change in policy.

In hospitals, when incidents happen, they are reviewed to see if changes need to take place. Errors aren't just swept under the table. Hospitals have personnel who do nothing but quality assurance.

There is always going to be anger at hospitals and medical personnel. It is one of the stages that people go through when they are grieving. When my FIL died, I was very angry at the hospital for not recognizing the signs that he had a bowel obstruction until he perforated. I had periods of anger over the care I received with my mastectomy. Today, I realize that this anger was good, it was just what I needed to distract me and help me get over the loss. I have been at both ends of this medical debate.

I agree Heather, a lot of the nurses with Bachelor degrees don't know more than the Associate degree nurses on the floor. Believe me, I ask questions all the time and see no difference at all. I also know a lot of Associate degree nurses who work in NICUs and ICUs, again experience counts more than the type of degree a person has. It might help them get a management job but not working in the units themselves. I also agree with you about nursing killing us. Probably close to half of the nurses on our floor are on blood pressure meds, most have back problems, some have heart disease.

Thank you Rita. I just came home from another crazy day. Usually Thanksgiving and Christmas are slow but for some reason we had a lot of very sick patients today. I got yelled at by one patient, for something that was not my fault. Yesterday, same thing. It's just about an everyday occurance; we get the brunt of the patients and family members anger, frustration, pain, whatever.

I really doubt I will make it to full retirement as a RN. I may have to work till I'm able to retire and go to work doing something else but I got burnt out the first year I was hired. Dayshift was better, better staffed but right now we've lost over half the new hires we've gotten and now it's not much better than night shift was. Tonight another new RN told me she was looking for another job. The RN who was hired with her has already left.

A lot of hospitals are now going to computerized medication administration, they have scanning bars on the meds. You scan the patient's armband and then scan the med. It cuts down on errors but being in a hurry, overworked, too many patients to care for, etc...and pharmacy not putting the correct labels on the meds can all work against you.

I can't really add much- several of you have profiled a nurses work well. But I can say, that pay is not routinely $35/hr. I am in northern Wyoming, and for a BSN with 30 years experience in ER, ICU, Open Heart Recovery, Labor/Delivery-High Risk, I get $16.00 an hour! In Driftwood, Texas, the pay starts at $18.76 an hour! So, those of you who think we are all high paid, think again. I earned $11.00 an hour 30 years ago as a new grad. (Detroit). My highest was $25.00/hr in Sarasota, Florida, 15 years ago. The pay there is still the same- I am still in contact with some nurse/friends. Also, a fellow grad in Rapid City, South Dakota is earning $25.oo/hr. And no, the cost of living is not lower here- Wyoming/Rapid has some of the higher cost of living. Cost of land has skyrocketed due to Californians coming here (and the farmer that sold the land for high price). My license plate last year for my new truck was $876.00 My VW Bug was $600.00 Electric-.09 perhr. Sweethart white bread $2.77/loaf. 8 oz Philadelphia Cream Cheese-$3.00 Gas- $3.79 diesel

Starting salary in my area, ilmbg, is around $19 per hour now for RNs. I do know some RNs who make about $35 per hour but most of them do not have a bachelor's degree, they're assoiciate degree nurses who've been working for years.

Yes, that is what I am speaking of- alot of people think an Rn routinely gets $35/hr.There are some who do earn more What part of the country are you from?

ilmbg, I live in Central KY.

It may be better to be a pharmacist, you would make much more money. In this area, they make over $70.00 an hour. It's very stressful but I don't think as stressful as a nurse.