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.

Dennis Quaid and wife Kimberly are suing the manufacturer of Heparin, a drug of which the couple’s newborn twins were administered an overdose last month.

According to a lawsuit filed Dec. 4 in Cook County (Chicago) Circuit court, the Quaids are suing Baxter Health Care Corporation, the company responsible for manufacturing and distributing Heparin.

The court papers claim that since the 10-unit vial and the 10,000-unit vials of the drug look the same.

Both, the papers say, "had a blue background color to its label. This fact made them more difficult to distinguish than if they had different background colors."

The Quaid twins were given a Heparin flush to clear out their IV tubes on Nov. 18 at Cedars-Sinai hospital, where they remained after their Nov. 8 birth.

"Instead of receiving the prescribed medication," the lawsuit reads, "a medical error was made by personnel of Cedars-Sinai Hospital and 10,000 units/ml of Heparin were administered instead."

As a result of an accidental overdose, the papers claim, twins "ZOE GRACE QUAID and THOMAS BOONE QUAID, suffered and will continue to suffer injuries of a pecuniary nature."

The couple is seeking $50,000 in damages.

The Quaids should also be suing the hospital. The nurse who gave the medication is 100% responsible for not looking at the number on the bottle to be sure he/she gave the right amount of medication. What’s more alarming is the fact that hospitals are not even supposed to be using Heparin to flush IV lines, especially on infant and pediatric units, but should be using normal saline instead. The person responsible for the overdose was the nurse, and according to initial reports the nurse also overdosed thirteen other infants at the same time.

Even someone who is not a nurse can clearly see the bottles have different colored labels, tops, writing on the label, and there’s a big difference between 10,000 and 10. The nurse was lazy, and he/she needs to pay for that mistake. Baxter should also consider making the 10,000 unit Heparin vial red. The hospital should implement a normal saline only IV flush policy like most other hospitals did more than 10 years ago.

Cedars-Sinai Medical Center’s Chief Medical Officer, Michael L. Langberg, MD, apologized to families, and to Dennis Quaid, for the grossly negligent accidental overdose of the blood thinner heparin given to his twin infants, and reportedly thirteen other infants in less than twenty four hours. Dr. Langberg said the error was "preventable" and involved "a failure to follow our standard policies and procedures." He said "there is no excuse for that to occur at Cedars-Sinai." Dr. Langberg went on to say after giving "two patients" protamine sulfate, they "indicated no adverse effects from the higher concentration of heparin or from the temporary abnormal clotting function. Doctors continue to monitor the patients." It’s a good thing they caught the error quickly.

Click here to read my full assessment of why this should never have happened. Heads are going to roll over this, and if they don’t there needs to be an outside investigation of the hospital by the State of California. Arnold only needs to make one phone call.

Click the link below to read Dr. Langberg’s entire statement.

Read More →

Dennis Quaid’s newborn twins, Thomas Boone and Zoe Grace, are now in the Intensive Care Unit of Cedars-Sinai Medical Center in Los Angeles. The twins were given 10,000 units of Heparin, a anti-coagulant (blood thinner) once on Sunday morning, and again on Sunday evening. Adults might get as much as 5,000 units of Heparin in a subcutaneous injection. The infants were given 10,000 units of Heparin in an IV, which is far more serious. The infants began bleeding everywhere, and are now being given Protamine Sulfate which is the antidote for Heparin.

The excuse from the hospital is that a technician stored the Heparin in the wrong place, and when a nurse grabbed the medicine for the babies without looking, it was the wrong dosage. As many as thirteen patients were mistakenly given the overdose of Heparin.

Nurses are supposed to follow the “five rights” of medication administration:

1) the right patient
2) the right drug
3) the right time
4) the right dose
5) the right route (mouth, intravenous, etc.)

If a nurse gave a medication without even looking at the drug, and drug dosage, he/she was giving to an infant then that person needs to lose their license immediately. Infants and children are given medication based on body weight because it is so easy to overdose them on any drug. Nurses working with infants and children receive special training to help them learn the math involved in calculating medication dosage based on a patient’s weight in kilograms. If thirteen infant patients were all overdosed on the same dose of Heparin, then that means that nurse did not even check the Heparin dose thirteen times.

More alarming is that the hospital said small doses of 10 units of Heparin are used to flush IVs. Many years ago the plastic needle in a patient’s arm was called a Heparin lock, and a small dose of very diluted Heparin was used to flush the plastic needle several times a day so it would not get plugged. However that all changed at least 10 or more years ago when the blood thinning effects of Heparin was considered harmful and unnecessary, so the plastic needles were from then on flushed with normal saline, and still are today, especially in hospital units caring for infants and children. When the plastic needle in patient’s arm started getting flushed only with normal saline, the name changed from Heparin lock to Saline lock.

Not only do lawsuits need to be filed, but hospital staff, and administration at Cedars-Sinai Medical Center need to be held accountable for this completely avoidable and horrible mistake.

A personal injury attorney wrote an article titled "Stop Me Before I Kill Another Infant With Another Heparin Overdose." In the article he writes:

"Administering an adult dose of Heparin to an infant is the type of error that should only happen once in the history of a hospital. But, here we have the incredible news that the same error occurred at the same hospital five years ago. Is there anything we can do to keep this hospital from killing infants?

Three infants have now died as a result of this repeated stupidity."

Click here to read the article.

The twins were born to Quaid and wife Kimberly Buffington November 8 via a surrogate mother.