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FACEBOOKI used to work at a pharmacy, and the meds were pulled by one person, filled by another, then checked by a pharmacist before being sent out. Even with all those people checking, we still got things wrong once in a while. I'm not saying it should happen, ever, but when you've got hundreds of orders that you're pressured to have out quickly, mistakes can and do happen.
Investigation Reveals How Hospital Gave Dennis Quaid's Babies an Overdose
Tuesday December 4, 2007
Tuesday December 4, 2007
Cedars-Sinai Medical Center Tuesday revealed just went wrong on Nov. 18 when three patients, including Dennis Quaid's infant twins, were given a near-fatal overdose of the anti-clotting drug Heparin.
"The medical center’s investigation found that preventable errors made by pharmacy and nursing staff caused the wrong concentration of heparin to be used," the hospital said in a statement.
"A pharmacy technician failed to follow hospital policy of having another pharmacy technician verify the medication and concentration prior to removing it from main pharmacy inventory. As a result, the technician mistakenly retrieved a higher concentration of heparin (10,000 units per milliliter) instead of the lower-concentration heparin (10 units per milliliter) used for flushing IV catheters.
"The higher concentration heparin was delivered to the satellite pharmacy that serves the pediatrics unit. A second pharmacy technician, working in the satellite pharmacy, did not verify the concentration of the delivery from the main pharmacy, as required by hospital policy."
The hospital's press release comes on the same day that Quaid filed a lawsuit against Chicago-based Baxter Healthcare Corp., maker of Heparin.
Quaid, who has not sued Cedars-Sinai, is suing the drug company because he wants to prevent it from happening to any other children. Quaid's attorney said three children died in Indiana from a similar mix-up with the drug.
Without naming Quaid's babies, Zoe Grace and Thomas Boone (who are now back home), the hospital said that "two patients were given protamine sulfate, a drug that reverses the effects of heparin and helps restore blood clotting function to normal. Additional medical tests and clinical evaluation conducted on the two patients found no adverse effects from the heparin or from the temporary abnormal clotting function."
“Although this was a rare event, and attributable to human error, it is also an important opportunity for the entire institution to explore any and all ways we can further improve medication safety,” said Michael L. Langberg, M.D., chief medical officer at Cedars-Sinai Medical Center.
“On behalf of the medical center, I extend my deepest apologies to the families who were affected by this situation, and we will continue to work with them on any concerns or questions they may have. This was a preventable error, involving a failure to follow our standard policies and procedures, and there is no excuse for that to occur at Cedars-Sinai,” Langberg said.
The hospital said that all employees involved in the accidental overdoses have been "relieved of duty pending investigation, and appropriate disciplinary actions are being taken."
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Posted by ken at 7:40 pm ET
Categories:
21 Comments
11:34 AM
Anonymous Says:
11:18 AM
Anonymous Says:
My personal supposition is that the hospital is not being sued because as we all know, human error is inevitable. We do all we can to prevent such accidents, but it is understandable even if not excusable. The hospital has said they are dealing with the employees internally. I would assume that the Quaids are happy with those actions or I would assume that they would want proof of repeated errors before suing, because the same error over and over is not acceptable and not at all understandable.
In the case of the manufacturer, they KNOW that there has been several cases of the same overdose happening. Not just the three infants who tragically died, but more who fortunately survived. Yet they still have not taken steps to change the labels, which are quite obviously too similar for such a large difference in the doses. A very simple step could have possibly prevented this. I mean, even some pharmacies offers different colored caps for prescriptions when there are more than one member in the household. It's not a new idea. It's not just up the hospital and their staff to do all they can to prevent human error; remember the manufacturer is also run by people. It is their product, the prevention starts with them.
10:57 AM
Anonymous Says:
11:32 PM Anonymous Says:
11:04 p.m. Have YOU ever seen the labels on Heparin? This was definetly a horrible, horrible tragedy for the Quaids, and thank goodness the babies are ok, but how would they know if the labels look the same?? I wasn't aware that Dennis Quaid was an actor, pharmacist, and doctor.
____________________________________________________
I have, It was all over the news when this happened. Google can be your friend. We're not talking top secret here.
10:13 AM
Anonymous Says:
Maybe there has already been a private settlement made with the hospital.
8:42 AM
Maya Says:
I find it odd that the hospital is not also being sued by them. You can't put 100% of the blame on the makers of heparin. Yes, they are at some fault, because those vials do look the same, and just for anyone who might question my credibility, I am a nurse and I do deal with heparin. The vials should be different colors to avoid this from even being possible. However, ultimately most of the blame goes to the hospital. In the hospital, when medicine is given to the patient, there are procedures in place to ensure that you aren't given the wrong medicine, dose, etc. There is no excuse to ever give the wrong dose. Things like these happen when you don't follow the proper procedure. Yes, it is very stupid that they package those vials similarly, but if you follow the procedures in place, guess what? You won't have these overdoses happening. It only takes a few extra seconds to double check what you are giving them. Another thing I almost wonder is if the hospital is short staffed. Many times the bean counters who have no clue how a hospital is run and probably have never been in patient care areas cut staff to help keep the profits up. You get a short staff and things get disastrous--you have less people with more work piled on them and that makes it more likely that people get stressed and rush things in an effort to get everything done.
8:19 AM
Anonymous Says:
It's the hospital's fault...
7:57 AM
belrose Says:
You sue whoever has more money ! I.e. "If one package was yellow and the other was red, this wouldn't have happened." There!
1:32 AM
Anonymous Says:
I hope they can fall in love forever. Someone here mentioned that they often go to pubspa.com in their spare time. I wonder what attract them.
1:31 AM
Anonymous Says:
So bad news
1:30 AM
Anonymous Says:
Love them
1:15 AM
Anonymous Says:
K well… wouldn’t it be the hospital’s fault for administering the drug improperly? You can’t exactly sue the manufacturers of Tylenol or whatever when some depressed adolescent overdoses and dies. It’s not so much the drug that is the issue as it is user-error. So whoever injected the 10,000 units of Heparin should be held responsible. Not the makers of the drug. That’s absurd.
Heparin is one of those drugs that need to be administered very carefully and monitored while it is in effect. Anyone in healthcare knows that. So they should’ve been more cautious. Idiots.
Better believe if it were my babies that hospital would be getting sued up the @ss. Get with it Dennis!
12:30 AM
Anonymous Says:
They should have the manufacturer make special extra-distinguishable labels, this happens with other drugs, manufacturers change the color, etc.
11:47 PM
Anonymous Says:
If it was not a famous person you would never have known, Cedars make millions of mistakes and bad care they are very rich they cover things up well, it is not the hospital you think it is
11:40 PM
ellenmiss Says:
old man and young lady!good partner , but this always is misunderstood by other people ,really their relastionship don't like those on sugarmommymeet?
11:32 PM
Anonymous Says:
11:04 p.m. Have YOU ever seen the labels on Heparin? This was definetly a horrible, horrible tragedy for the Quaids, and thank goodness the babies are ok, but how would they know if the labels look the same?? I wasn't aware that Dennis Quaid was an actor, pharmacist, and doctor.
11:04 PM
Anonymous Says:
The human error could have been prevented if the manufacturer had taken steps, specifically the changing of the labels as they are very much alike.
10:36 PM
vilzvet Says:
9:51: Tell me about it! It's absolutely sickening these spammers. Don't ever click on those sites, people! Supposedly they are filled with computer viruses.
10:33 PM
Anonymous Says:
Why sue the manufacturer? This was a human error.
9:51 PM
Anonymous Says:
9:45, stop coming on here and acting like you're a normal person reading and commenting to these posts. You're nothing but an advertiser and making those dumb comments aren't fooling anyone. Not to mention, no one cares about your stupid site.
9:45 PM
Gimme a gumball Says:
Maybe they are just sueing for the cost of money they're out of that insurance doesn't cover. And to be awareness and change so this crap doesn't happen to innocent people ever again.
9:45 PM
jazz887 Says:
Oh, bad news. I just learned something strange at her blog at the celeb site millionairecupid.com a few days ago. What's wrong with the hospital? Why did they do that? I'm so confused.
