Did Heparin Mix-Up with Insulin Contribute to Infant's Death?

Saskatoon, SaskatchewanNot long ago actor Dennis Quaid made headlines after his infant children were given an adult dose of heparin in the hospital, rather than the formulation meant for infants. An investigation determined the labels of the two formulations were too similar. Well, it has happened again—sort of. This time, in Canada. And this time, insulin was mistaken for heparin injection due to a similarity in the label.

The Leader-Post of Regina, Saskatchewan, reported October 22nd that four infants in the neonatal intensive care unit at Royal University Hospital were mistakenly given insulin, instead of heparin, back in August. The hospital noted that all four infants were in the same unit, so when their health began to deteriorate, doctors were able to diagnose the situation quickly and resolve the mix-up. The babies' collective health had begun to mysteriously deteriorate, prompting nursing staff and doctors to look more closely at the situation.

It was then that they discovered the infants were being given "Humulin R," rather than heparin. Officials are of the view that the similarity in the labeling, together with a crowded pharmacy, are responsible for the error.

Heparin side effects are in themselves a concern, given that they could lead to a Heparin allergy that can sometimes prove devastating. A woman in the UK, currently embroiled in a school transportation issue involving her 14-year-old daughter, lost an arm and a leg to a Heparin reaction in 1997.

Heparin can have an equally devastating impact on infants, as the Quaids painfully discovered. However, other drugs can pose a potential hazard if administered incorrectly. In the Canadian case, while doctors were able to stabilize the four infants administered insulin in error, there is little data on the long-term effects of insulin on infants, according to Dr. Laurentiu Givelichian, a neonatologist quoted in the Leader-Post story. He noted that there were no studies of blood-sugar deprivation in premature babies—requiring close monitoring of the three surviving babies.

Sadly, one of the four babies died. Andrew Delbert Gordon Washam succumbed two weeks after the mix-up, at the age of 44 days. Dr. Givelichian noted that the autopsy revealed the cause of Washam's death to have been a severe lung infection, and officials with the Saskatoon Health Region say the infant's death was not the result of the medication error.

However, Bonnie Washam, Andrew's mother, takes a different view and is considering legal action against the Saskatoon Health Region. "After they gave him the insulin, he got pneumonia, and after that he just wasted away," she said.

Humulin is a brand name for insulin and was labeled as such. The medication was found to have been in close proximity to heparin at the time of the mix-up, said Sandra Blevins, vice-president of clinical and operations support for the region. "We don't know what happened for sure. It could have been a moment of distraction. It could have been an issue of look-alike labels: Humulin and heparin located side-by-side in those bins. It could have been a mis-filing of the labels at the time they were printed. We don't know," she said.

An adverse reaction to Heparin injection is bad enough, coupled with the kind of close call the Quaid family experienced when two formulations of heparin were mixed up. In this case, however, administering the wrong medication entirely magnified the error.