The Machine Was the Perp: Wrong drug errors

Most American hospitals place automated drug dispensing cabinets on the patient floors, to enable nurses to give drugs to patients more promptly. Usually this is a good thing, but the convenience comes with an awful high hidden price.

The families of six premature babies, and hospital staff, have learned that grim lesson. The babies were being cared for in the neonatal intensive care unit of an Indiana hospital. The NICU was equipped with an automated drug dispensing machine--imagine a candy machine that requires a nurse's password instead of money to activate. A pharmacy technician had stocked it with the ADULT doses of heparin, a powerful blood-thinner meant to prevent blood clots that could clog intravenous tubes. Then, over time, as nurses opened the cabinet's drawer to get heparin for their preemie patients, they took the adult heparin, and gave it to six different preemies. Three of the babies died and three remain in critical condition.

Advice to hospital pharmacy directors: Store hazardous medications in the pharmacy, not in the automated dispensing machines, to prevent multiple errors.

Advice to parents: Check the label of each dose of medication your family member receives. In choosing a hospital, ascertain whether hazardous medications are stored in automated dispensing machines. A patient advocate may be useful for this purpose.

Read another of our stories about a drug error lawsuit, or read more about this one in "Family of 3rd preemie to die of overdose speaks" and "Drug Error Triple Tragedy in Indiana."