Hospital Changes Policy Due to Quaid Twin Overdose

When HG first reported on the Dennis Quaid twins being overdosed on Heparin, I wrote that more than 10 years ago hospitals stopped using Heparin to flush IVs, and started using normal saline. I also said the hospital in this case needed to change their policy. Well, they did, and now the hospital is using normal saline FINALLY. Maybe someone at the hospital reads HG, or maybe they just realized a huge lawsuit was not worth continuing to live in the danger zone. People reports:

Cedars-Sinai Medical Center – the facility which treated Dennis Quaid’s twins when they were mistakenly overdosed with Heparin – announced several changes to hospital policy Tuesday.

"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," the hospital’s chief medical officer, Dr. Michael L. Langberg, said in the statement.

Among the key changes, the hospital will flush catheters in the pediatric unit with saline solution, not the anti-coagulant Heparin. Quaid’s twins, Boone and Zoe, were among the three patients overdosed when their catheters were accidentally flushed with a solution containing 10,000 units per milliliter of Heparin, not the usual 10 units per milliliter.

The hospital has also beefed internal training on the use of "high-alert" medications. Furthermore, all employees involved in the incident were suspended.

"The individuals involved in this incident were immediately relieved of duty pending investigation," said the statement, "and appropriate disciplinary actions are being taken."

It’s about time, but even though the hospital is flushing now with normal saline in pediatric, and I’m assuming in the infant/neonatal unit as well, they need to flush with normal saline everywhere in the hospital. This a half step forward. It’s not enough. If you know anyone at the Cedars-Sinai, tell them to read the HG article here, and make the appropriate changes.