"Lessons Learned: The Aftermath of the Heparin Event at Methodist Hospital"

A tragic mix-up of heparin vials at Methodist Hospital in Indianapolis resulted in the deaths of 3 NICU patients. Vials of heparin, 10,000 units/mL were inadvertently placed in the drug cabinets in place of heparin, 10 units/mL. The 1000-times more concentrated heparin was used to flush IV catheters.

Jim Eskew, RPh, MBA, Director of Pharmacy for Clarian Health Partners will discuss how the error occurred, the hospital's action plan (long term) to address the error, management and support of staff and lessons learned in response to the error. Valerie Shahriari, JD, RN, Director of Risk Management and Patient Safety will discuss the investigation, analysis of the error and communications with the families, press and public. She will also discuss dealing with the various regulatory agencies. Deb Ward, RN, BSN, Manager of the Methodist NICU will review the impact of the errors on the nursing staff involved in the errors as well as the entire NICU staff. Deb will review how Clarian supported the staff, communicated to parents of other NICU patients and assisted the six nurses directly involved with the errors.

To access the program, go to:
https://attewc.webex.com/attewc/lsr.php?AT=pb&SP=EC&rID=55295407&rKey=4E9B8676791C1094