Hospital Procedures Questioned After Death of Two Babies

INDIANAPOLIS, Sept. 19, 2006 — -- In her sixth day of life, tiny Thursday Dawn Jeffries struggles to survive. She is one of six premature babies accidentally given 1,000 times the prescribed dosage of the blood thinner heparin. It's a chilling example of the dangers human error can pose during a hospital stay.

"I think it was wrong. My baby was fine before they gave her the heparin," Thursday's mother Heather Jeffries said.

The overdose also killed two baby girls in the neonatal unit at Indianapolis' Methodist Hospital and left four fragile infants seriously ill. The problem stemmed from a mixup of nearly identical vials, which resulted in the babies receiving an adult dosage of the drug.

"Ultimately, the blame for our errors falls upon this institution, a weakness in our own system has been exposed," Methodist Hospital CEO Sam Odle said.

It was a terrible mistake that is alarmingly common, according to a recent study by the Institute of Medicine in Washington, D.C. In a report released this July, the group found that every hospital patient in this country is subject to an average of one medication error a day, resulting in 1.5 million people a year suffering some harm from medication mistakes.

"They are not the most common error, but … they are likely to cause harm, likely at a higher rate than any other error," according to Dr. Wilson Pace at the University of Colorado.

The frequency of errors varies substantially across the country, and a number of hospitals use technology to avoid making mistakes in treating patients.

Some hospitals already use a bar-code system to match patients with the proper drugs. Others use computerized prescription orders to avoid mistakes made by sloppy handwriting.

And the Food and Drug Administration is now regulating the names of drugs so they are more distinct. For instance, the name of the pain reliever Celebrex is quite similar to Celexa, a drug used for clinical depression.

In Indiana, a patient safety center has been opened to identify problems at specific hospitals and to bring experts in to try and fix them.