Medical malpractice can happen to anyone. And last week while we celebrated Thanksgiving, actor Dennis Quaid was running back and forth to the hospital because it happened to his two-week old twins when they received a massive overdose of a drug. And it happened at the well-regarded Cedars-Sinai Hospital in Los Angeles.
Now the kids will hopefully be OK despite this, as the overdose was realized and an antidote given. But it’s a good lesson on how to make improvements in the mechanic of how hospitals work and how drug companies package their products. If only people would listen.
The kids had IV lines flushed with Heparin, a blood thinner. They were supposed to be flushed with an infant’s dose of 10 units/ml. But they got an adult’s dose of 10,000u/ml instead. So they received a 1,000x overdose. Oops.
And worse yet, the hospital had previously been warned by the FDA of the potential for mix ups between these two doses.
Here are the questions for the hospital and the drug manufacturer:
What were the adult strength drugs doing in the neonatal unit?
Why do the bottles look the same?
Why weren’t there precautions in place to separate out different dosages?
Why were FDA warnings ignored?
The way to prevent these errors and “near-misses” is to put processes into place in health care like we do in aviation safety. Make it hard to do the wrong thing. Labels should have “red alerts” to show different strengths. The background colors on the bottles should be different and the font size needs to be increased. Look alike drug names should be differentiated by using TALL LETTERS. (glipIZIDE vs. glyBURIDE). The bottles should look completely different so it is obvious to every care giver…whether stocking a med cart or administering a medication.
If you think this is a rare occurrence, think again: Each year there are over 1.5 million medication errors in the United States, and as many as 7,000 people will die from them. And our children are the most likely victims (see: Children Are Most Likely Victims of Surgical Medication Errors).
But sometimes, it takes celebrity misfortune to bring home the reality of the problem.
- Medical errors are not always doctors’ fault (Malpractice via Kevin, M.D.)
- Heparin Overdose in Three Infants Raises Safety Questions (MedPage Today)
- Medication Errors (FDA)
- Dennis Quaid Twins Update: Hospital Was Warned About Heparin Dangers (Babble)
(Eric Turkewitz is a personal injury attorney in New York)
Update (12/4/07): Dennis Quaid Sues Baxter Healthcare Over Heparin Label Mixup for Twins