My usual routine was to get up pretty early and visit Emily before breakfast, around the time that the staff changed over. On this morning it was my favourite nurse Suzie who was to look after her. There had been concerns overnight as Emily had been very up and down. One of her main lines had 'blown' and tissued into the arm, her monitoring was all over the place and it was noted that some of her old puncture wounds had started to bleed. I was reading through her overnight notes and started to ask Suzie about the fact that her suctioned secretions had been blood-stained - at almost the same moment Suzie had realised that this wasn't just Em being difficult - but that there was something fairly seriously wrong. Things developed pretty quickly, Suzie took down the heparin immediately and called the team over. Her clotting was way off (they couldn't clot the sample at all in the ICU machine and the labs which came back later noted the same) It transpired that the heparin pump had been refilled overnight and because of a lack of clarity in the prescription Emily had been given 10x her normal dose.

It shook my faith quite a bit as you can imagine. But I have to say that it was well handled by the Head of Intensive care and the Head of Nursing Services. They were very 'upfront' with regards to what went wrong and I saw the prescription for my myself immediately after the incident. Thankfully it led to protocols being changed surrounding the writing of prescriptions for that particular drug. I was saddened to learn though that another child died from the exact same overdose following open heart surgery in another children's unit just two years ago. This led me to speak with PICU again recently to confirm that the protocols remain in place.