Hep-Lock (Heparin)

Heparin, manufactured by Baxter Healthcare Corporation, is an intravenous blood thinner with a very narrow therapeutic window, which means that the dosage at which it is effective is very close to the dosage at which it is toxic.  As a result, the administration of Heparin must be carefully controlled. Many people have been injured as a result of accidental overdosing of the version of Heparin named Hep-Lock, and others by exposure to contaminated batches of Heparin. 

The ten-unit bottle and ten thousand-unit bottle of Hep-Lock used to be similar in size and both were colored in shades of blue. In the right lighting, it was difficult to tell them apart.  Baxter eventually changed the labels and bottle coloring in order to prevent these problems.  However, Baxter did not recall the old bottles of Hep-Lock.  As a result, hospitals still used the poorly-labeled bottles of Hep-Lock, leading to some horrifying experiences, including hypotension (low blood pressure), organ damage, organ failure, and death.

The children of actor Dennis Quaid received Hep-Lock when they were eleven days old. In November of 2007, the twins were hospitalized for staph infections at Cedars-Sinai Medical Center.  They were given Hep-Lock, but thanks to the confusion in packaging, instead of receiving ten units they received ten thousand units.  This caused their blood to flow freely internally and from all external wounds.  At one point, blood from a wound in son Thomas’ spine “spurted six feet across the room and splattered on the wall.” 

In September of 2006, a hospital in Indianapolis had experienced a similar mix-up and three infants died.  Three other infants were seriously injured.