Medicinal Mix-ups in Children Happen with Alarming Frequency

Deerfield, ILIt's hard enough when your child is in hospital, suffering from injury or disease. It is every parent's mission, indeed instinct to protect his or her child from harm. And so imagine the horror when you are notified that your child, whose health is already compromised, has been made even more gravely ill as the result of being administered an overdose of medicine.

Incredibly, such calls are made 540,000 times each year. That's more than a half-million children who are harmed, due to medicinal mix-ups. It works out to about one out of every 15 kids, or 7 percent of hospitalized children.

Statisticians could make the case that 7 percent is a low number, and please remember that 93 percent of children in the United States receive the right dosage.

However, parents and child advocates will tell you that 7 percent, is simply 7 percent too much. One child, is one child too many, let alone the other 539,000. That's someone's child. That's also a defenseless human being who is too young to understand what is happening to him or to her. All they know is that they hurt bad, and Mummy and Daddy are crying because they can't do anything to help, and now that the nurse has come in and stuck a sharp needle in my arm, now it hurts even more, and I'm crying and I don't understand what's wrong.

Yes, statistics be damned. According to the results of a research study published this past April in the medical journal 'Pediatrics', this happens 540,000 times a year.

"Drug delivery errors are a big problem," said Les Funtleyder, a securities analyst who follows the health-care industry for the New York investment firm of Miller Tabak & Co. "Unfortunately, this occurrence is more common than anyone would think."

The reasons are thought to be numerous. Overworked healthcare workers, who are tired and prone to errors while working through the fog of exhaustion, is but one problem plaguing the system. Another has to do with the speed, and rapidity which often is required in the delivery of healthcare, especially in a crisis situation, or within a busy environment where there are constant distractions.

It doesn't help, therefore, when vials of adult, and pediatric medicines—with vastly differing strengths—are provided in extremely similar vials.

Such was the case with injectable heparin manufactured by Baxter Healthcare Inc. On several occasions in 2006, and again in 2007 infants were mistakenly given heparin from adult vials, because the packaging was similar. It has been reported that doses of pediatric, and adult heparin were shipped, and stocked in similar-sized vials, and both featured blue labels, although with a different shade of blue.

One could make the case that in the highly charged environment of a children's ward, or the ER itself, such subtle differences could be easily missed.

Case in point: it was on September 16th of 2006 that infants Emmery Miller and D'myia Alexander Nelson, 2 and 5-days-old respectively, died at Methodist Hospital in Indianapolis. Two days later the hospital announced new safety precautions and training for staff. But that didn't prevent a third infant from dying the next day.

On September 21st of that year the families of the deceased infants called on Baxter Healthcare to update the packaging on injectable heparin, in an effort to avoid future tragedy.

Baxter Healthcare did, indeed, issue a warning letter to health care workers, and announced a re-design of the heparin labeling to better distinguish adult doses, from the infant strength. But Baxter is said to have not recalled existing vials, with older packaging.

Nine months later, in a highly publicized case, the infant twins of actor Dennis Quaid were accidentally given overdoses of heparin. Mercifully, the twins survived. The Quaids have since sued Baxter Healthcare, but the suit has yet to be resolved.

"We hate to see any medication errors with our drugs," said Erin Gardiner, a spokeswoman for Baxter Healthcare Inc., which is based in Deerfield, Illinois. "But whenever you have a human component involved, there's always a risk of error. That's why it's so important for clinicians to read the name and dose of drug before giving it to a patient."

The Baxter heparin incidents are but a few examples of, as the report in Pediatrics suggests, a much wider problem. This past July 14 babies at a hospital in Corpus Christi, Texas were sickened after they were administered heparin that was 100 times more potent than appropriate for children of that age group. Hospital workers mixed the heparin in the hospital lab. It was not known if fatigue, carelessness or mislabeling was to blame. Of the 14 infants that fell ill two later died, although the hospital claims the deaths were not related to the heparin overdoses.

Still, it remains a problem—and as 2009 dawns in a few months, it is expected that more than a half-million children, statistically speaking, will be victims of medicinal mix-ups. Some will die needlessly.

And their parents will sue, in their memory.