Mark Graban's leanblog.org - Lean Healthcare, Lean Hospitals, Healthcare Kaizen, Lean Thinking, Lean Manufacturing, Toyota Production System

Lack of Error Proofing Kills 3 Babies

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This is an incredibly sad, and completely preventable, situation. Three babies are dead, and three more injured, because the wrong drug was administered to them at an Indianapolis hospital.

Let's keep in mind, first, this quote from the World Health Organization:

“Human error is inevitable. We can never eliminate it. We can eliminate problems in the system that make it more likely to happen.”

This quote could easily come from Toyota leadership. This is why they error proof. You want to prevent good people from making mistakes. My point is to look at this situation by NOT pointing fingers of blame at an individual.

The situation and the news stories:

Initial story about the first two deaths from a local news station

CBN story, again after the first two deaths

“At the newborn intensive care unit of Methodist Hospital, the staff is blaming the newborn deaths on human error. Somehow the wrong dose of a blood-thinner medication, Heparin, was stocked in a hospital drug cabinet.

President and CEO of Methodist Hospital, Sam Odle, said, “They're both one-milliliter vials. One has 10,000 units of heparin, one has 10 units of heparin…so the nurses — knowing they only carry one dose on the unit — took the vial out and administered it to the patients.”The mistake proved deadly.In all, six premature babies were given adult doses of the drug. Three babies are in stable condition. Another is in critical condition. Two babies died.”

A lot of the initial response was focused on “a nurse made a mistake.” Situations like this are far more systemic and wide spread than to think a single person and a single mistake led to this.

A nurse said:

“I have always been confident that the drug that I'm looking at is the drug that's in the drawer,” said a nurse. “But, of course, it's still my responsibility to assure it's the right drug.”

Since this was a CHILDREN's ICU, you would wonder why an adult-dose drug was ever there. The nurse is saying that it should NOT have been there. But still, a nurse did not read the label, she ASSUMED. That's just one mistake. A better process would be to ALWAYS double-check the drug name and dosage. The drug should have been labeled “Heplock” but it was actually “Heparin” that was loaded into the cabinet. Heparin has been in the news before when adults are killed because “Heparin” was confused with “Insulin” (same vial, clear liquid, etc.).

Looking at future PREVENTION, the CBN article says:

“Under new guidelines, the hospital staff will double-check drug labels and remove certain doses of the blood-thinning drug, heparin, from their unit.”

Now the second part sounds like an error-proofing step…. but removing the drug that already shouldn't have been there is very reactive. How do you prevent the adult-dose drug from getting there? What process was responsible for that?

The Washington Post news story, after the third death
has some more details:

“According to hospital officials' account, a pharmacy technician had loaded the cabinet with heparin, at 10,000 units per milliliter, instead of hep-lock, at 10 units per milliliter.”

So we had one mistake, a tech from a different department loading the wrong drug. The nurses, far too trusting of the system, didn't double check the label and assumed, incorrectly, that they have the wrong drug — partially lulled to sleep by the technology that you might expect to prevent this. There is a cabinet in the ICU that requires a nurse to enter their ID code and a patient code — it prevents the wrong DRAWER from being opened. But, it doesn't address the issue of a pharmacy tech loading the wrong drug. How is that error-proofed?

Everyone is pointing fingers, some of it system related (how does the drug maker help make the packages more distinct, so Heparin and Heplock aren't confused?)

The mother, and we can't possibly have enough sympathy and empathy for her pain and suffering, she says:

“The nurses is what I'm blaming. They need to lose their licenses is what I am saying so it won't happen again to the other babies,” Jeffers said.

I'm sorry, but that's not going to prevent other deaths. Everybody in the system, particularly the nurses, were probably trying their best. We need to improve the SYSTEM to prevent it from happening at Methodist and at other hospitals. Was this a one-time error?

“Methodist has acknowledged two other heparin mix-ups involving babies in 2001, and said both infants recovered.”If this was an isolated incident I would say that it would be solely the responsibility of the person at the hospital,” Lee said. “But this is not an isolated incident.””

The five nurses and pharmacy technician involved are on leave and receiving support and counseling, and are expected to return to work, Odle said.

I'm sure all of the hospital employees feel sick over what happened. I know I would. Hell, I read about this yesterday and I had basically a nightmare where I was working with a pharmacy and trying to get them to improve, mistakes were still being made and I was yelling at people (and I'm not normally a yeller). This kind of situation really bothers me and reinforces my mission to work in lean healthcare.


When I'm back to work at my client tomorrow, I'm going to talk with a pharmacy tech I know and get her perspectives on this, what procedures would be in place at their hospital to prevent this kind of situation.

People need to “be careful” but that isn't enough. As the quote up top says, people are human. Blaming “human error,” as the hospital did doesn't mean “what individual screwed up?” It means, humans designed a fallible system. We need to try harder to design error-proofed systems, whether in healthcare, aviation, etc. In the current situation,d either in it takes MULTIPLE errors for a death to occur, but it still happens too often.

There are over 5,000 hospitals in the U.S. This kind of error could happen (and probably does) at any of them. My question is this — what kind of network is in place to share situations like this? EVERY hospital in America (and the world) should be looking at their own processes today to prevent THIS problem. With the internet and modern communications, each hospital shouldn't be operating in a vacuum. One mistake ANYWHERE should be enough to drive change and process improvement EVERYWHERE. We don't need to make the mistake at each hospital before each hospital fixes the process.

Do we have any Intel readers who could share how “Copy Exact” communication among the fabs takes place? Sure, a network of 5,000 hospitals under different ownership is one thing compared to a smaller number of fabs all run by one company, but I'm sure lessons can be learned.

One lesson for me — if I had a baby in the ICU (or any loved one in the hospital), I would be there and would monitor each and every drug that was ever administered. If a nurse is offended, so be it.

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Mark Graban is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is an anthology titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus. His next book, to be released in 2018, is Measures of Success.

8 Comments
  1. […] looking learn from mistakes of others. What if Cedar Sinai had asked that question when the babies were killed in Indianapolis? He said “the answer was yes” (it could […]

  2. […] might remember me blogging about the Indianapolis incident where three babies died after being mistakenly  given an adult dose of heparin back in 2007. The same set of failure modes […]

  3. […] Here’s a picture of the two drugs that were mixed up when the three babies were killed at the hospital in Indianapolis last week. […]

  4. […] Quaid was right to say the errors were “avoidable” — pointing out it was the same avoidable errors as the case where three babies died at Methodist in Indianapolis. […]

  5. […] the hand wringing when they realized this COULD happen at Cedar Sinai? Did they read the news about the Indianapolis case from 2006 and think “well we’re better, it couldn’t happen […]

  6. […] 2006: Heparin error kills 3 babies in Indianapolis […]

  7. […] I hope there’s some good discussion on the show about systemic errors and the need for prevention. How can we prevent this same error from occurring again at other hospitals with other babies? Don’t forget the same error occurred, with fatal effects, in Indianapolis a year earlier: […]

  8. […] didn’t learn from the series of preventable mistakes that killed three babies in an Indianapolis hospital  in 2006, leading to the 2009 overdose of the Quaid twins (which they survived, […]

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