Dennis Quaid's twins given overdose in hospital blunder

[nonconformist]

LOS ANGELES (AFP) — Actor Dennis Quaid's newborn twin children were in serious condition in a Los Angeles hospital on Tuesday after a blunder that saw them given massive overdoses of an anti-clotting agent, a report said.

Quaid's children -- Thomas Boone and Zoe Grace -- were in intensive care at Cedars Sinai Medical Center after being given a dose of the drug Heparin more than 1,000 times larger than the normal amount, website TMZ.com reported.

Heparin is used to flush out intravenous tubes and prevent blood clots. Babies typically receive 10 units of the drug but Quaid's children were given 10,000 units on Sunday before the alarm was raised, according to TMZ.com.

<snip>

Quaid's children were born to the actor and his third wife Kimberly Buffington by surrogate on November 8.

More... http://afp.google.com/article/ALeqM5hETiTfZ-3H_8GouVni3zhwRMUS-A

[amitten]

1. No surprise. I got OD'd at a hospital once by a drugged-up

nurse.

She acted like she was chock-full of Darvocet. After giving me my injection (thank God it was only Benadryl) I had to run to the bathroom with vomiting and, well, the other.

When I got back she said, "Oh, I should have looked at your weight. I gave you twice what I should have."

Glad it wasn't something stronger!

[emilyg]

2. A lot of these errors go unreported.

[Audio_Al]

19. We had a simple pharmaceutical error that wasn't caught for a whole year.

Finally, the patient demanded to see the chief of the department. He was consulted and picked up the dosing problem immediately. Somebody wrote down 175 instead of (0)75. That was all it took. If the patient had been in compromised health, she might have died. As it was, there was a year of worry and weird tests, but there was plenty of unnecessary suffering.

We complained. We got compensated. We're not supposed to talk about it. Don't let the bastards get you down.

[LeftCoast]

3. Heparin should ALWAYS be double checked by another RN

This happens frequently enough that most hospitals require Heparin be confirmed with another RN before administering it. Insulin is one of the only other drugs I know of that you need to verify. Someone really f*cked up here.

I hope those little babies are ok.

[FloridaJudy]

31. This used to happen a lot

Back when I was a hospital RN in the seventies. Drugs that are prescribed in "units" (like insulin and heparin) were particularly chancy: a doc's bad handwriting easily allowed "10u" to be read as "100". This even happened to me. It slipped by me, another RN and the pharmacist - the dose we gave was within reason, if a bit high. Thank the gods the patient suffered no harm! From then on any doctor who didn't write out "units" got a severe reprimand.

But hospitals have had three decades since to get it right. They now have computers, automated med carts and pre-packaged unit doses. Are they still relying on some sleep-deprived Resident's hastily scrawled orders and some overworked nurse's hasty oversight?

[Hoof Hearted]

4. If we are lucky enough to conceive, I'm birthing at HOME!

Infertility is so unbelievably painful. Only those who have been through it have any idea whatsoever. To go through that and then have something like this happen?

After that much Heparin I'm shocked they're still alive. My prayers go out to those little babies.

[Didereaux]

5. Not possible! a fully insurance run medical system simply can't screw up!

[Thothmes]

28. Do you think that a fully government run medical system would do any better?

[nonconformist]

32. Maybe not, but at least then everyone would be able to get mediocre medical care

Instead of just those fortunate enough to have insurance.

[Thothmes]

33. Fully agree

[rainbow4321]

38. Gigantic screw up at my old hospital....

Adult ICU nurse went to deliver a body of a patient to the morgue..noticed a "bag" in the morgue and took it upon herself to throw the bag away in the biohazard trash. Why someone would take anything OUT of the morgue is beyond me.
Turns out the "bag" contained an infant who had passed away...don't know if it was that a mom miscarried or if the baby had made it to the NICU and passed away but it was small enough to go in a small (body) bag.
Head honchos dug thru the biohazard trash but never could recover the baby. The parents later returned to the facility to recover the baby for a burial only to be told that the baby's body was thrown away. Haven't heard anymore about the whole thing.

[Sacajawea]

43. Sounds like what happened at, I think, Mercy Hospital, Rockville Centre, NY...

a couple of years ago, iirc.

[underpants]

6. That is horrible

Best wishes to them

[Berry Cool]

7. If you ever want a real scare, open the pages of a nursing magazine

and turn to the column where nurses write in anonymously to describe dosing errors or other blunders they made, and advise others how not to make the same mistake. All kinds of stories in there about giving the wrong drug to the wrong patient, giving too much or too little, etc.

[nonconformist]

8. Ack!

You know, this is one of the main reasons I didn't go into a medical field - there's no room for error. I think you have to be FULLY dedicated to a job like that.

[Le Taz Hot]

40. I recently decided to go to nursing

school (at 52). We had a test in which there was a separate numbered answer sheet. I missed a line and got off-number and ended up missing 4 questions unnecessarily. After I got the test back I recognized what happened, mentioned it to the instructor, who then told me, "You mark the wrong box with a real patient you could kill them!" It scared me so bad I quit nursing school the next day. I think I'll go back and renew my teaching credential instead.

[begin_within]

9. Another problem is that doctors change so frequently that one doctor may

order something that another doctor decided the patient shouldn't have. This happened to my Mom in the hospital a couple of years ago, when the doctors making "the rounds" rotated, and the new doctor didn't realize my Mom's history of hemmoraghic stroke, and prescribed Coumadin, a blood thinner. Fortunately I was there all the time, and when the nurse came in with the first dose, I questioned her and said that they previous doctor had decided to avoid all blood thinners. She called up the new doctor and he cancelled the Coumadin. So you really have to be there all the time and be the patient's advocate and stay on top of every single thing they are doing. They often fail to do what the doctor ordered (such as ambulate the patient 4 times per day) or do something wrong, like crush a pill that can't be crushed because it's time-release, etc.

[nonconformist]

10. My friend's aunt died from an overdose of Coumadin

But it was exactly what the doctor had given her. They've been fighting a legal battle over this for years now.

[begin_within]

12. Sorry to hear that

I think they prescribe stuff far too easily in hospitals. Every time you turn around, some doctor has come along and added another medication to the patient's chart. Before long it turns into a pharmopoly, with 20 or even 30 medications, and the patient loses touch with reality, and it's hard to tell what's causing what. They should be far more cautious and conservative with medications, in my opinion.

[EFerrari]

17. You are so right. After one day when we found my grandma's hand

swollen like a grapefruit from a malplaced IV, my family has never left anyone in the hospital alone again. Never. The staff does rotate so it really is up to the family to make sure that there is consistency.

[Audio_Al]

22. Luckily, we've only had day surgeries and we go together.

We stay with each other until they come for the gurney. We ask a lot of questions.

The last time I went with my wife, they had some young thing placing the IV -- it hurt. After try number TWO, we told her in no uncertain terms to GET A MORE EXPERIENCED PHLEBOTOMIST STAT and she did.

[Cha]

11. That's too bad..

Poor things! I hope they get well!

[Audio_Al]

24. On the other hand, we have a friend who has two kids with twin-to-twin syndrome.

They were born in August (premature from November) and both were in the NICU for MONTHS. Twin to twin syndrome is FATAL in most cases (one twin gets more blood than the other).

The mother and dad and two older brothers practically LIVED at that hospital. Now, Kelsy and Karly are cute, healthy almost 7 year olds.

Thanks to Emmanuel Hospital staff here in Portland.

[rocktivity]

13. According to ABC News online

...a pharmacy technician mistakenly stocked the 10 unit vials and 10,000 unit vials in the same drawer. Protocol at the hospital is to keep the different units separated.

"This was a preventable error, involving a failure to follow our standard policies and procedures," the hospital said. "Although it appears at this point that there was no harm to any patient, we take this situation very seriously." (link)

I'll sure mention this to my sister at Thanksgiving dinner tomorrow--she's a hospital pharamcist.

:headbang:
rocknation

[nonconformist]

14. Lots of interesting stuff from the video clip on that link

6% (!!) of infants fall victim to medication errors in the hospital. Also, at another hospital 3 babies died due to a similar accident, also involving Heparin.

And thankfully, Quaid's babies are in stable condition now.

I find it interesting that the hospital is saying that there was no harm to any patient, but it's being reported by ABC that the babies almost died, but now they're stable. I wouldn't say that's "no harm".

Seems this is shining some attention on hospital blunders in the media, which is good news.

[Audio_Al]

15. Pediatrician on TV today says that drug can cause internal bleeding.

The bleeds could be anywhere, but the worst place would be bleeding in the brain.

The babies are 5 and 6 pounds, and I think she said they were fraternal (boy and girl)... not sure.

[rocktivity]

27. Their names (Thomas Boone and Zoe Grace) certainly suggest they're a boy and a girl

Their development (physical AND mental) will have to be watched VERY closely--perhaps for the rest of their lives.

:(
rocknation

[rainbow4321]

37. Then it falls on the nurse who drew up from the wrong bottle...

And I say this being a nurse myself. Yes it was a system/policy error but the last line of defense is the bedside nurse. I could see it happening, you reach into the accudose machine (where stock drugs are kept) and into the little slot where the heparin bottle is supposed to be, you **assume** the right bottle is in there and off you go to draw up and give the med.
The hospital must not have scan medication/patient computer technology yet or a policy in place where 2 nurses check EVERY drug given to their babies in the NICU. I imagine they do NOW, not that "now" does much good for the patients who got the wrong doses already.

[Audio_Al]

16. The hospital submitted a statement admitting the error and apologizing.

This hospital has such a good reputation! WTF?

People should lose their jobs over this shit!

How sad! I hope they survive undamaged.

Respectfully,

Audio Al

[EFerrari]

20. Yes, this is one of the very best hospitals in L.A.

And errors like these is why I signed out a.m.a. both times as soon as my kids were washed and weighed.

The staff must feel terrible and scare and it makes no difference to those babies.

[KitchenWitch]

18. They are trying to blame it on the pharmacy tech

saying that the tech put it away on the wrong shelf. The pharmacist supervises the techs, sorry, Pharmacist, this one is on you...And the RN who administered it without looking at the bottle.

[Audio_Al]

21. They should have safeguards and double checks in place.

In our pharmaceutical case, the HMO primary doctor said, "Sorry." The nurse who wrote down the numbers wrong said she "didn't remember."

No excuses. One mistake can kill and often does.

[KitchenWitch]

23. Agreed.

My point was, that the pharmacist in charge basically shuffled his/her responsibility onto the tech, who really is in no position to be held accountable for the mistake. The pharmacist is making the big bucks because the accountability for errors of that nature should lie on his/her shoulders, and on his/her license. Pharmacy techs are registered, but they do not hold professional licenses, they do not carry malpractice insurance, but the pharmacists do.

[Audio_Al]

26. I don't know about hospital management and where they will place responsibility.

Seems as if everybody along the way dropped the ball. I don't know the details, but two different strengths in similar looking bottles? -- kept in the same drawer? --

When I take medications -- all in the same white bottles -- I look at the bottle label when I take it out of the storage area, look at it again when I take the pill, and look at it a third time when I put the bottle back.

Nevertheless, I have mistaken Alprazolam 0.5 mg. for Lovastatin 10 mg., but only once. (They are both orange colored tabs.) I had put them in a pill pod in the wrong order.

I guess it will be up to the hospital staff and perhaps the courts as to where the ultimate responsibility and culpability lies. Let's just hope and pray these kids make it.

What a tragedy...

[nonconformist]

25. I definitely think the RN that administered the shot is the most culpable

The pharmacist holds some responsibility for this too, as you point out they are the professional that is over the techs.

[leftchick]

29. check, double check and triple check

when giving medication. Always!

[earth mom]

30. Wow-that is really sad news-I hope they are okay!

:(

[Audio_Al]

34. My son-in-law, a doctor, said the biggest risk is a brain bleed.

But the two twins are said to be doing OK and there were pictures last night of Quaid taking them home -- or at least carrying them in two infant seats.

The matter was discussed on CNN last night, along with some other fearsome problems with a painkiller I have never heard about...

Let's just hope all goes well with those kids.

Respectfully,

Audio Al

[undeterred]

35. At U of Chicago there was a pt killed with a 10x dose of chemotherapy

The order was written incorrectly by a tired oncology resident and administered by a nurse who didn't double check it. The patient was being treated for a form of testicular cancer, which is highly curable. When he became sicker within hours they realized the mistake, but there was nothing they could do, and he knew he was going to die in a matter of days. He was 34.

Lots of procedures changed after that.

[Audio_Al]

39. Wow. That's so very sad. Let's hope Cedars really give a look to that situation.

Let's pray it never happens again to anyone else.

[undeterred]

41. In this situation they really did change a lot of procedures

because there should be multiple checks on anything that important. The whole situation of residents being up for 24 hours at a time is a problem in itself, as is nurses being afraid to question doctors. After that, everyone began puttting patient safety first.

[Audio_Al]

42. I thought most hospitals have now abandoned the requirement that puts doctors on call for 24 hours.

My wife was married briefly to a young resident doctor in Miami who was on that schedule.

Her husband was a zombie during his first year of residency and they had to move to Hartsdale, New York so the couple could live with his widowed mother-in-law -- due to the lack of finances plus the long hours.

The marriage only lasted one year due to that stress, plus the birth of a stillborn daughter which catapulted my wife into a postpartum depression.

Respectfully,

Audio Al

[rainbow4321]

36. 2 nurses are supposed to check the drug given to infants

before giving ANY DRUG, even Vitamins w/ iron in them (we had a baby given an overdose of iron, hence that new policy). Standard policy at most all places with babies. WTF happened???? It said a third patient also rec'd the wrong dose. Same nurse with three babies in her assignment, I wonder? My old facility used armband/medication scanning..wrong drug/patient and it beeps/won't scan, tells you're wrong.
If it wasn't at the nurse level then I would say someone in pharmacy mixed up the wrong dose and sent it to the unit. No way for a nurse to tell what the concentration is if the label has what it SUPPOSED to be in the syringe. Normally, though, the nurse draws it the heparin fresh from the heparin bottle at the bedisde. In this case, the WRONG heparin bottle (heparin comes in adult units (10,000) bottles and infant units (10).