Dennis Quaid Recounts Twins' Drug Ordeal

Actor Tells 60 Minutes' Steve Kroft Medical Errors Kill Thousands

(CBS)  Because the deaths occur one at a time, all over the country over an extended time period, Quaid says the issue has slipped under the public's radar. "It's bigger than AIDS. It's bigger than breast cancer. It's bigger than automobile accidents. And, yet, no one seems to be really be aware of the problem," he says.

The causes range from misdiagnosis to surgical errors to medication mistakes like the accidental Heparin overdose that that nearly killed the Quaid twins, an occurrence that’s not all that unusual, according to Diane Cousins. She's the vice president of U.S. Pharmacopeia, a non-profit public health group that maintains one of the largest databases on medication errors.

"What we see with Heparin is that it is almost always in the list of top ten drugs that are reported for medication errors, and almost always in the top ten that are harmful," Cousins tells Kroft.

"What is it about Heparin that there's so many mistakes?" Kroft asks.

"Well, Heparin is very commonly used in the hospital. And the number of opportunities for error are very high," she explains.

But Cousins says another contributing factor with Heparin is labeling that can easily lead to mistakes. The 10-unit pediatric dose and the 10,000-unit adult dose come in vials of identical size and shape and in different shades of blue that can easily be confused, if not seen in reference to each other. And they are not the only drugs with that problem.

Asked to give some examples, Cousins, showing two medications, tells Kroft, "In this case, we have a solution of Lidocaine, which is an anesthetic often used to swab a child's throat or mouth for mouth pain. Here, you have lithium oral solution used for manic depression."

"Lithium is not something you'd wanna give a child. Absolutely not," she says.

The two small vials Cousins used as an example both have blue caps and cluttered labels, but one contains a hormone and the other a children's antibiotic.

"If you're at arms' length, it's hard enough to read these labels because of their type size," Cousins says.

"And I'd need my reading glasses," Kroft remarks.

Baxter International, which manufactures the Heparin given to the Quaid twins, was fully aware that there had been fatal mistakes that may have been caused by confusion over its labeling.

When the three infants in Indianapolis died after receiving an adult dose, Baxter issued a nationwide safety alert, and last October began shipping Heparin with a redesigned, peel-off label to end the confusion. What it didn't do was recall the old stock that was sitting in hospitals all over the country, including Cedars-Sinai in Los Angeles.

"And as a result, our kids were given an old stock which was basically the same packaging and form that the kids in Indiana had gotten. Now, they recall toasters. They recall trucks. They recall dog food that came from China last year. But they don't recall medicine that kills people if you give it in the wrong dosage," Dennis Quaid tells Kroft.

The Quaids believe that Baxter was the first link in a series of events that led to the overdosing of their infants and they're suing the company for negligence on behalf of their children.

[jd7cole]

DR.MARK C. ADRIAN ,AT SCRIPPS MEM. HOSP LA JOLLA FOUND THAT MY MOTHER HAD A BLADDER INFECTION. HE SAID HE THOUGHT IT MIGHT BE A GOOD IDEA TO KEEP HER OVERNIGHT "MERELY FOR OBSERVATION", WHICH WAS DONE. A NURSE ON 7W, NICHOLE L. BECK, (MY MOTHER POINTED HER OUT TO ME), STUFFED SEVERAL PILLS DOWN HER THROAT, IN RAPID SUCCESSION, AND LEFT HER ALONE RESULTING IN MY MOTHER CHOKING HORRIBLY FOR MANY MANY HOURS. AFTER THAT SHE COULD NO LONGER EAT OR DRINK AND THEREFORE REQUIRED A SOMACH TUBE. SHE LASTED ONLY A SHORT TIME ON THIS

[reedzone]

Thank you for your excellent reporting on the Quaid
twins and hospital mistakes, that cost so many lives.
It is a real problem that is like the elephant no one
acknowleges and no one is accoutable for.
The medical community in my small town murdered my
son because he had a disability and they withheld
treatment that could have saved his life, and
chose not to. They are getting away with it because
I cannot find a lawyer who will take the case, first
they agree to take the case and then they say they
can''t and withdraw. Now the two years is up and they
got away with it. Rae a Reed 435 755 0915 I would like someone to do a story about how the most helpless people the disables are treated by the medical community.
in this country.

[nurseangel85]

No Hollywood special effects for us. We are, and will remain, human, not super heros. The fixes of Hollywood won''t change that Mr Quaid, but we can do something you can''t inspite of our short comings. Save lives.

[igrowbabies]

"Quaid calls it a conspiracy of silence, where doctors protect nurses, nurses protect hospitals, insurance companies protect drug manufacturers."

This is one of the most arrogant comments I have ever heard from a notoriously arrogant lot of people...actors. Of course, this is why you, 60 minutes, gave him center stage in the first place and let him make such a statement. Need I remind you that we are the ones in the trenches every day, working under circumatances you don''t ''get'' unless you do it. In spite of our best efforts, we make mistakes... because every move, every hurried calculation and decision can become one as in any other job, only ours can be fatal. We get that. We lose sleep over it. He gets to ''retake'' and ''remake'' his day at will. We are educated enough to know how easy it is to screw up. Yet, we are brave enough to get up and give it another day. Would he? To suggest we cover up for one another is disgusting to me. Shame on all of you. Walk in my shoes for the 15 years I have done it, work holiday''s weekends, days and nights then we''ll talk because only then will you be qualified to judge the likes of us.

[mbushkin-2009]

Can you put me in touch with Mr. Quaid? I would like to tell him about our unique personal health record. Its focus is to reduce medical mistakes and thereby save lives, improve the quality of medical care and reduce care costs. Thank you.

[valeriesc1]

My mother passed away at Ronald Reagan Medical center last month. From the time she was taken to their ER until she died, it was a nightmare including one of the more senior lab technicians commenting that she had been given twice the amount of a drug that she should have for her weight and size. She never woke up after that. She was injured iserting the catheter so there was blood in her urine. She was given a neck brace that was too big and caused her great anguish and discomfort although she did not need the brace. We had to raise the roof to get any information. No consistency with attending "physicians" -- all "practicing" doctors, rarely a doctor with experience since our primary physician was a Cedars. Registered letter sent to UCLA Medical Center CEO and head of Patient Services but no response.

[onemora]

I feel for the Quiads, and hope that their children experience a long happy life and all that it has to offer. I also feel for myself and my family. My husband died because of a medical error. It could have been prevented by BARCODE. It is not ridiculous to sue the drug companies. They package medicine in look a like bottles and bags. They need to mandate BARCODING. It''s easy to sue the hospital and doctors. But let''s go to the top and demand a better system. We are at the mercy of drug companies. Due to their greed my grandchildren lost their grandfather, my children lost a father, and I lost the love of my life. I was given a charm at age 19 with the saying, "Grow Old With Me". I didn''t get the chance. It was stolen from me.

[sela6]

As the attorneys for the Quaids in their lawsuit again Baxter Healthcare Corporation, we commend the Quaids for their continuing efforts in speaking out about pharmaceutical safety, defective products, medication errors, and other issues impacting patient safety. At Susan E. Loggans & Associates we believe that every person has a right to recovery if he or she has been wronged.

[kcurna]

Everyday I go to work I am charged with the responsibility of caring for my patients but ensuring no harm comes to them. I am the gate keeper for every physician and departement I am their closest advocate. There is a Nursing shortage that will reach pandemic levels my 2020. One million Nurses will be needed and probably 999,999 of them will be at the bedside. The job is difficult at best and there are hundreds of processes that don''t improve outcomes. Place Nurses behind the maphia screen and let them tell you how many policies and procedures are written to comply with JCAHO but don''t improve outcomes. Then you will have a story. Checklists and charting mandates steal time from patients. How ironic despite the ever increasing Patient Safety Standards; medication errors remain on the rise. Insanity defined, keep doing more of the same thing while expecting different results.Why was an adult dose of heparin even on a pediatric floor? Pharmacy surely had a hand in distributing the wrong medication. But as we all know the Nurse holds the bag every time and the weight of that bag is killing the profession.

[intellidot]

It is distressing to see how widespread an issue this has become. In fact a 2002, study commissioned by the American Medical Association found that almost 1 in 5 medications administered in the 36 typical hospitals reviewed were in error*.

Your viewers should know there is a way to solve and prevent medication errors through technology called barcode point-of-care (BPOC) medication safety solutions. These are wireless, hand-held devices which scan barcodes on medications and patient wristbands at bedside to make sure medications are given accurately. The devices can even check for allergy and drug interactions as well as documenting important information about whether pain medications are working.

Mr. Quaid was correct -- let%u2019s not wait for another fatal medication error to occur %u2013 consumers should be asking their hospitals before checking in if they have bar-code point-of-care medication safety technology as part of the criteria in determining which facility to get care from %u2013 just like picking your primary care physician %u2013 you need to investigate whether your hospital uses handheld, bar-code technology.

IntelliDOT Corporation
San Diego, California

*Medication Errors Observed in 36 Health Care Facilities by Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD; Gientte A. Pepper, PhD; David W. Bates, MD, MSc; Robert L. Mikeal, PhD.

[firepelley]

Where humans are involved, there will be mistakes. Yes, even to the Quaids. There are ways to limit this. What is suing the drug company going to do? As Mr. Quaid mentioned, medical mistakes are a significant issue. If he truly cared about the issue, he would get educated about it and maybe bring attention to it. The similar labels are such a tiny portion of the swiss cheeze that has to have all holes lined up in order for a mistake to fall through. Although they have the highest payout. Systems in medicine and error prevention is a whole science in and of itself, but not quite as glamorous as suing a major pharmaceutical company.

[flash19472]

I was dissapointed that Mr. Kroft did not point out the that the two products involved in the medication mix-up had two different names. The pediatric product is called HEP-LOK whereas the adult product is called Heparin Sodium. These names were approved by FDA. Today FDA is doing everything in their power to prevent medication errors. The bottom line is there is no substitute for a Health Care professional who knows which is the adult and which is the pediatric drug product. I was also dissapointed that Mr. and Mrs. Quaid did not explain why they did not sue Cedar Saini but choose Baxter instead. It was clearly stated in the segment that Cedar Saini made the mistake.

[flash19472]

I was dissapointed that Mr. Kroft did not point out the that the two products involved in the medication mix-up had two different names. The pediatric product is called HEP-LOK whereas the adult product is called Heparin Sodium. These names were approved by FDA. Today FDA is doing everything in their power to prevent medication errors. The bottom line is there is no substitute for a Health Care professional who knows which is the adult and which is the pediatric drug product. I was also dissapointed that Mr. and Mrs. Quaid did not explain why they did not sue Cedar Saini but choose Baxter instead. It was clearly stated in the segment that Cedar Saini made the mistake.

[flash19472]

I was dissapointed that Mr. Kroft did not point out the that the two products involved in the medication mix-up had two different names. The pediatric product is called HEP-LOK whereas the adult product is called Heparin Sodium. These names were approved by FDA. Today FDA is doing everything in their power to prevent medication errors. The bottom line is there is no substitute for a Health Care professional who knows which is the adult and which is the pediatric drug product. I was also dissapointed that Mr. and Mrs. Quaid did not explain why they did not sue Cedar Saini but choose Baxter instead. It was clearly stated in the segment that Cedar Saini made the mistake.

[flash19472]

I was dissapointed that Mr. Kroft did not point out the that the two products involved in the medication mix-up had two different names. The pediatric product is called HEP-LOK whereas the adult product is called Heparin Sodium. These names were approved by FDA. Today FDA is doing everything in their power to prevent medication errors. The bottom line is there is no substitute for a Health Care professional who knows which is the adult and which is the pediatric drug product. I was also dissapointed that Mr. and Mrs. Quaid did not explain why they did not sue Cedar Saini but choose Baxter instead. It was clearly stated in the segment that Cedar Saini made the mistake.

[marielouise4]

My heart goes out to the Quaids for their ordeal and nearly losing their precious babies, but it''s ridiculous to sue a drug company for a human error made at the hospital. The nurse should have double-checked the label. If she gave those babies 1,000 times the dose of Baby Tylenol, should the Quaids then sue McNeil? Baxter has deep pockets so that''s where the attack has been aimed.

[missourik]

This hospital is listed on the internet as being accredited by JCAHO. They could be contacted with any problems of this nature. They can be contacted by patients, patient guardians/parents, or even employees. They come in and do a complete review of the problem and require the hospital to respond. Most people do not know that they exist unless they have actually worked in a hospital setting. Here is their website: http://www.jointcommission.org The phone number for complaints is 800-994-6610. Please look at the JCAHO website and then go to http://www.csmc.edu/ and put in JCAHO in the search block in the upper right corner of the page. It will come up with some of the items that are looked at. It sounds like it is time for another review. JCAHO can be called at anytime.

I also believe that the medicine should have been recalled in addition to the nurses and rest of the staff being more careful.

I have worked in the quality and risk management arena of hospitals and have also been on the receiving end of having major surgeries six times in my life. Just prior to the last one, I asked them about the drugs they were getting ready to use during my surgery - I was deathly allergic to one that is commonly used for irrigation - she thanked me for asking as that drug was in the mix. That would have been an error on their part as it was written all over my records! I would not have hesitated to call JCAHO. Life is too short as it is.

[missourik]

This hospital is listed on the internet as being accredited by JCAHO. They could be contacted with any problems of this nature. They can be contacted by patients, patient guardians/parents, or even employees. They come in and do a complete review of the problem and require the hospital to respond. Most people do not know that they exist unless they have actually worked in a hospital setting. Here is their website: http://www.jointcommission.org The phone number for complaints is 800-994-6610. Please look at the JCAHO website and then go to http://www.csmc.edu/ and put in JCAHO in the search block in the upper right corner of the page. It will come up with some of the items that are looked at. It sounds like it is time for another review. JCAHO can be called at anytime.

I also believe that the medicine should have been recalled in addition to the nurses and rest of the staff being more careful.

I have worked in the quality and risk management arena of hospitals and have also been on the receiving end of having major surgeries six times in my life. Just prior to the last one, I asked them about the drugs they were getting ready to use during my surgery - I was deathly allergic to one that is commonly used for irrigation - she thanked me for asking as that drug was in the mix. That would have been an error on their part as it was written all over my records! I would not have hesitated to call JCAHO. Life is too short as it is.

[id3458781]

Very disappointed in lack of in-depth reporting- felt like I was watching Entertainment Tonight! Steve Kroft accepted to put a Band-aid on a gaping wound. I applaud any drug manufacturer that improves their packaging to increase safety, but the real problem here is that any drug can kill if not properly adminstered- all nurses are taught to check the "5 R''s" every time they administer medication, even OTC: Right Patient,Right Drug, Right Dose, Right Route and Right Frequency. The nurse screwed up-but why? That could be the real story, but it''s not as glamorous- nurses, along with most health care providers, are notoriously overworked and underpaid, again a symptom of a broken health care system. If we, as a nation, recognized the need and value of our health care providers, and invested in our health care system ( not the insurance carriers or the pharmaceutical companies), it would be the first baby step to correct what will be a catastrophic problem as baby boomers age, bacteria become resistent to antibiotics and our medical issues become more complex and difficult to treat.
Idaho RN

[ricca6]

I know how to stop medication errors in all areas of the hospital. I am an OB RN in a hospital. We use the Mac System. A barcode on the mediation must be scanned and the barcode on the patient''s bracelet scanned or you can not give the medication. This is done by way of a computerized system and both barcodes must match. Please get me in touch with Dennis Quaid.