Heparin overdoses in infants

March 25th, 2008

Preventable medical error leads to celebrity activism
In November 2007, Actor Dennis Quaid and his wife Kimberly nearly lost their newborn twins when a nurse erroneously injected the infants with the wrong dose of heparin, an anti-coagulant frequently used in low doses to keep IV lines open.

The twins have recovered despite their ordeal, but Quaid has not. He is using his outrage and celebrity status to launch the Quaid Foundation, a non-profit organization whose mission is to expose the frequency of medical errors, break the conspiracy of silence surrounding them, empower and educate the public to their rights as patients and by doing so, raise the standard of patient medical care.

In a recent interview on CBS’ 60 Minutes, Quaid told the nearly tragic story that that has lead him to his new calling as an advocate for those who are not so lucky.


Heparin overdoses result in death
In September, 2006, 6 premature babies at Methodist Hospital in Indianapolis were given adult doses of Heparin instead of the weaker solution used for clearing IV lines. Three of the infants died as a result of the lethal mistake.

The multiple mistakes resulted when the neonatal unit’s drug cabinet was stocked with the wrong strength of drug. The error was partly attributed to the similarity of labeling on the drugs. Baxter, the drug manufacturer, changed the labeling on the adult dosage heparin bottle but did not recall drugs already sold. The drug administered to the Quaid infants did not have the new label.


What hospitals can do
The Joint Commission, which accredits hospitals, is requiring that hospitals have programs in place by the end of this year to reduce the likelihood of harm from anticoagulation therapy using drugs like heparin.

But Mike Cohen, president of the Institute for Safe Medication Practices, which monitors and analyzes errors and maintains an updated list of high-alert medications, says that safety efforts are largely voluntary and that too few hospitals have invested in technologies such as bar coding that could sharply reduce errors.

Hospitals are also calling on patients and families to act as a final line of defense, keeping a watchful eye on medications and asking nurses to verify their accuracy -- especially when infants and children are involved. "Kids are changing every day, and administering medications in doses according to size and weight adds a new level of complexity," says Charles Homer, a professor at Harvard University and chief executive of the National Initiative for Children's Healthcare Quality.
(source)


Medical malpractice suits
Holding doctors, hospitals, drug manufacturers, and other medical professionals accountable for their errors in court has been one avenue to securing damages for patients and families who have been needlessly harmed.

But these suits have done little to change the policies and procedures of the medical industry that continues to be protected by both a conspiracy of silence among their rank and file as well as corporate lobbyists who’ve made it their mission to vilify the injured and the lawyers who represent them in their pursuit of justice through the courts.

In fact, tort reform (the term given to chipping away at our individual rights to seek justice) has been effectively enacted in California where a cap on medical malpractice awards has made finding a lawyer to undertake a malpractice suit is difficult. (One family's story)


An informed public
The families of the infants treated at Methodist Hospital retained a lawyer and are likely to file medical malpractice suits.

The Quaids have not yet decided on whether or not to sue Cedars-Sinai. They are hoping that their celebrity will help publicize the serious problem of medical mistakes in this country that go largely unnoticed. Medical Error is one of the leading causes of death in our country – more than auto accidents, breast cancer or AIDS. It goes largely unnoticed because these deaths are unconnected by cause, timing, or geography.

Public outcry and pressure on institutions and medical professionals to become accountable for their deadly errors is needed before any meaningful change in the medical industry can be expected.