In 1999, the U.S. Institute of Medicine (IOM) released To Err is Human: Building a Safer Health System, a report that focused on the stark prevalence of medical error occurrences in our society. It concludes that medical errors do not occur solely as a result of individual recklessness, but rather due to the failure of a system. The report laid out a four-tiered comprehensive strategy by which the health care industry and government could reduce the rate of preventable medical errors. Though great strides have been made since the release of this report, medical errors, specifically related to medication administration, are still predominant. Famously in 2007, actor Dennis Quaid’s twin infants were administered an overdose of Heparin at Cedars-Sinai Medical Center in Los Angeles.
In November 2007, Dennis Quaid’s 12-day-old twins were admitted to Los Angeles’s Cedars-Sinai Hospital for treatment of staph infections. During hospitalization, the infants were each prescribed 10 units per milliliter dose of Hep-lock, an anticoagulant used to keep IV catheters open and maintain smooth blood flow in the catheter. Instead, both infants were twice mistakenly administered 10,000 units per milliliter of heparin, a stronger dosage appropriate for adults that is not intended to be used as a flush for intravenous catheters. A lethal overdose of this kind results in rapid prolongation of coagulation time and active bleeding. Upon recognition of the overdose, the infants were administered protamine sulfate, an antidote used to neutralize the effects of heparin. The Quaid family was not informed of the incident until they arrived to the hospital for a visit the following day. In fact, during a telephone check-in with an on-duty nurse that evening, Quaid was informed that the infants were fine, despite what was occurring.
After more than forty hours, the coagulation levels began to drop and both infants stabilized. After spending several days in intensive care, both infants made a full recovery. Today, they are 10 years old and show no signs of lasting damage from the overdose. Just one year earlier, however, three infants died and three more were injured as a result of similar overdoses at Methodist Hospital in Indianapolis. Both incidents involved heparin manufactured by the pharmaceutical company Baxter Healthcare Corp.
The case of the Quaid twins is multifaceted, with a number of factors that potentially contributed to the errors that were made. Two of the six rights for safe drug administration were miscarried: right drug and right dosage. As previously discussed, the infants were prescribed 10 units per milliliter dose of Hep-lock but instead received 10,000 units per milliliter doses of heparin, 1,000 times the prescribed dosage. This mistake was made not once, but twice with each infant. According to Quaid v. Baxter Healthcare Corporation (2009), 100 vials of 10,000 unit per milliliter of heparin were sent to the pediatric unit by pharmacy technicians, rather than the proper 10 unit per milliliter vials of Hep-lock. Additionally, according to Dennis Quaid’s testimony before Congress, three members of the nursing staff handled the drugs: a nurse who prepared the drug, an instructor nurse, and a student nurse. The nursing staff failed to read the label thoroughly prior to administration. The Quaid family, however, places most blame on Baxter Healthcare Corp., alleging that the 10-unit vial of Hep-lock and the 10,000-unit vial of heparin were virtually indistinguishable in labeling and size. In fact, the similarity of the labels of the two vials had also contributed to the overdose of the infants at Methodist Hospital just one year earlier.
The Quaid family reached a $750,000 settlement with Cedars-Sinai by which the hospital agreed to make radical changes to prevent such an overdose from occurring again. These changes included electronic record keeping, bedside barcoding, and computerized physician-order entry systems. The hospital is also said to have taken steps to provide additional training to staff and review all policies involving high-risk medications. Additionally, the hospital now flushes pediatric catheters with a saline solution, rather than heparin. It was reported that the individuals involved in the incident were relieved of duty pending investigation. This action is certainly fair, as patient safety is of the utmost concern and priority. It was reasonable for the individuals involved to be relieved until a thorough investigation had been conducted. The Quaid’s also filed a suit against Baxter, alleging that the two products were dangerously indistinguishable. Additionally, though Baxter had released new product labeling shortly before the November 2007 incident, those vials had not yet made it to the shelves of Cedars-Sinai. The company failed to recall or repackage the vials when they had knowledge of the infant deaths that had occurred as a result of medical error with these products.
In my opinion, the overdosing of the Quaid twins was the result of a chain of events, beginning with Baxter Healthcare. The company, knowing of the fatalities that had occurred, was negligent in taking the necessary steps to prevent further tragedies involving the high-risk drug heparin. However though, the drug vials were handled by multiple hospital personnel who should have been diligent in handling such a high-risk drug. As a nurse, it is crucial to be aware of sentinel events and incidents occurring within your field of practice so that you may learn from them and initiate a quality control review of your own practice if necessary. Every hospital and pediatric nurse should have been informed about the tragedy that occurred at Methodist Hospital and taken time to review their own policies and procedures regarding that particular drug. A nurse must thoroughly consider the six rights for safe drug administration for all administrations, no matter how routine or how high risk the drug is.
Since the incident, Quaid has become an international advocate for patient safety. In 2008, Dennis and his wife established the Quaid Foundation, which later merged with The Texas Medical Institute of Technology. The foundation aims to raise awareness about the gaps in the medical system and the dangers of medication errors, as well as seek ways to improve medical safety for both patients and healthcare personnel. Though errors still occur, and the United States has not yet met every goal of the IOM’s report, the healthcare industry continues to make strides in drug administration error prevention. With the increased awareness and focus on proper drug administration, as well as the continued evolution and incorporation of technology into the healthcare sector, the incidence of drug administration errors should decline. Additionally, nurses are more well-educated and well-trained than ever before with the IOM’S Future of Nursing Report’s goal for 80 percent of registered nursing to hold baccalaureate degrees by 2020.