Medication Errors Continue; This Time Placing Actor Dennis Quaid’s New Born Twins at Risk
A horrifying story has come to public light due to the inexplicable overdosing of Dennis Quaid’s new born twins with a 1,000 times overdose of a very dangerous blood thinning drug called Heparin. According to an L.A. Times story the Chief Medical Officer at Cedars-Sinai, where the error occurred, called this “a preventable error”. Apparently someone mixed up vials of this dangerous medicine and mistakenly used 10,000 units per milliliter as opposed to the intended 10 units per milliliter. Amazingly Quaid’s twins were not the only victims. Apparently there were as many as 7 other children also overdosed. Fortunately, hospital staff noticed the errors and administered medication to reverse the effects of the overdose. Although hospital officials stated there was no harm to the children, they were admitted to the Neo-natal ICU. How does this happen and why are reasonable measures not taken to prevent this type of error?
What is particularly frightening is that the health care professionals apparently, according to Cedars Sinai, failed to follow the hospital’s own policies and procedures. Can failing to follow written guidelines be chalked up to simple “human error” and blithely swept under the rug? Shouldn’t measures be evaluated and implemented to assure this can not happen again? Shouldn’t the hospital’s response have been more along the lines of: we acknowledge this happening and have launched an in-depth investigation to evaluate methods to be employed that will prevent risking the lives of patients in this manner?
Corporate America seems to be fond of the “human error” classification; perhaps because it leaves the impression that “stuff happens” and nothing can really be done to have prevented it. This cavalier “answer” also is an effort to minimize governmental or community scrutiny; and the potential legal ramifications that can arise from these needless tragedies. Clearly, having in effect policies and procedures that are not followed doesn’t have any meaningful impact on the core issues. As in many things in life, and in Corporate America, when it comes to real solutions it should be less about what you say or write, and much more about what resources you commit to an issue.
The solution to this escalating trend of medication errors is proactive action as opposed to reactive band aids. Cedars-Sinai indicates effective immediately they are going to re-train 1,800 members of their staff. In addition to this, one would hope that this time they also plan not to exclude, pre-scheduled periodic re-training as opposed to a post hoc response to what could have been a catastrophic loss of life? Indeed, many times the dirty little secret associated with these errors does not see the light of day, as medication error cases involve not only deficiencies in training, and meaningful quality control monitoring systems, but also chronic understaffing. It appears sometimes when administrators and/or CEO’s become consumed with their business landscape they fail to appropriately weigh concerns for safety needs and trade off for their fiscal desires. Profits over safety in the arena of consumer safety are never an acceptable trade off. Obviously each case is unique, but these errors do not appear to be diminishing. According to the L.A. Times article just last year three babies died at Indiana hospital under nearly identical circumstances. In that case a pharmacy technician appeared to be the root cause.
In fact, two months ago a jury in Polk Count awarded a Florida family $25.8 million dollars in a case called Hippely vs. Walgreens. This tragic case also involved a pharmacy technician and a known potential deadly blood thinner that as in these other cases was filed with many times the prescribed desired dose. Isn’t it time safety issues associated with training, oversight, and at the very least, updated special precautions for known high-alert medications are enacted? It is easy enough as the Institute for Safe Medication Practices publishes a high-alert medication manual that pharmacies and medical centers alike can use as a starting point to create new procedures when handling these potentially lethal drugs.
It is time for serious government and consumer oversight to convert what appears to be lax industry measures. We need to require reportable actions so consumer can see what if any progress is being made on this critical consumer safety and health arena. The public has the right to know the truth, and what is being done to correct these problems.
Sadly no one knows just how frequently these errors are occurring, because there are no uniform mandatory reporting systems established. Also, if by good fortune no one gets hurt in a given case, it is still an important indictor of the frequency of errors and should be reported. I know the old adage about if a tree falls in the woods, but I’d sure like to know if the woods I am getting ready to go hiking have a 30% ratio of falling trees! Last, one wonders whether anyone would ever have heard about if it were not for the fact these twins were the children of a famous actor. I say that because sadly I don’t recall any national news stories involving the horrific deaths of those three babies killed in the similar overdose incident in the Indiana hospital. If it did exist, I certainly don’t recall it drawing near the attention this recent story rightfully has.