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Abstract
IN SEPTEMBER 2006, A HOSPITAL IN Indianapolis, Indiana, reported that six premature babies had been given adult-size doses of heparin, resulting in the death of three of the infants.1 The adult doses of this blood thinner had inadvertently been placed in a medication cabinet in the NICU. Similar packaging of the adult and neonatal doses contributed to this human error. When used correctly, medications can save neonates’ lives. When incorrectly used, they can cost the lives of the very patients they are intended to help.2
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