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Full Statement from Cedars-Sinai

11/21/2007 12:26 AM PST BY TMZ STAFF

Statement of Michael L. Langberg, MD Chief Medical Officer, Cedars-Sinai Medical Center:

On November 18, three patients who were receiving intravenous medications as part of their treatment had their IV catheters flushed with a solution containing a higher concentration of heparin (a medication used to keep IV catheters from clotting) than normal protocol. As a result of a preventable error, the patients' IV catheters were flushed with heparin from vials containing a concentration of 10,000 units per milliliter instead of from vials containing a concentration of 10 units per milliliter.

The error was identified by Cedars-Sinai staff, who immediately performed blood tests on the patients to measure blood clotting function. Four additional patients in the unit were tested as a precaution. The tests indicated that four of the seven patients had normal blood clotting function, and three had tests indicating prolonged blood clotting function. In one of the three patients, the clotting tests returned quickly to normal. The other two patients were given protamine sulfate, a drug that reverses the effects of heparin and helps restore blood clotting function to normal. Additional medical tests and clinical evaluation conducted on the two patients indicated no adverse effects from the higher concentration of heparin or from the temporary abnormal clotting function. Doctors continue to monitor the patients.

I want to extend my deepest apologies to the families who were affected by this situation, and we will continue to work with them on any concerns or questions they may have. This was a preventable error, involving a failure to follow our standard policies and procedures, and there is no excuse for that to occur at Cedars-Sinai. Although it appears at this point that there was no harm to any patient, we take this situation very seriously. We are conducting a comprehensive investigation, cooperating fully with the Los Angeles County Department of Health Services and will take all necessary steps to ensure that this never happens here again.

COMMENTS

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1.

liz    

soooooooooo sad i have a little girl she spent 1 week in the nicu at m hospital its tuff and its a sad time i hope mr quaid have some piece through this diffult time.,

2343 days ago
2.

martha    

I guess it's comforting to know that hospitals screw up even when celebrity patients are concerned! It is so scary! Remember Dana Carvey who went in for heart surgery and they operated on the wrong side of his heart? You have to become your own health advocate when in need of medical care and check every little thing instead of ASSuming that the nurses and hospital personnel will do as they are supposed to. My husband recently went in for rhinoplasty (devaited septum) and I was with him pre-op. The OR nurse came in to do an EKG and I asked why. She told me "we always have to do this on patients before their heart surger!" I kid you not. I explained to her (not very calmly either!) that he was here to have his nose operated on. Disaster fortunately averted in that case, but unfortunately that doesn't always happen. Best wishes to Mr. and Mrs. Quaid and their twins!

2343 days ago
3.

Lori    

I'm glad you got that straightened out Martha. In defense of nurses, since I have been practicing for 21 years. It is very easy to become distracted by all sorts of interference while we are trying to give the best care possible while dealing with widespread shortages of qualified nurses. I applaud your statement about being a health advocate, however, there is a fine line between being an advocate and being in the way. The next time you or a loved one is in the hospital please USE THE NURSE CALL BELL. You are not bothering us by using the call bell. YOU ARE bothering us when we are charting, pouring medications, dealing with other patients' issues and you walk up, excuse yourself and proceed to report that your family member needs a glass of water or their pillow fluffed. Something that could and should wait to be addressed by the next AVAILABLE nurse who answers the call light. You also need to understand that what we do may seem unusual, for instance, in my hospital we ask a patient their name and birth date before EVERY procedure, medication, testing etc. Patients complain that this is monotonous, they try to make jokes and give the wrong dates to see if we are paying attention. THIS IS HOW WE ARE ASSURING YOU ARE THE RIGHT PERSON for the treatment, procedure, medication etc... Your little jokes are a waste of our valuable time.
As for your husband having an EKG, that is standard for any surgery where general anesthetic is being used, even if it's just a hangnail. Today, everyone is watching and waiting for nurses and doctors to make a mistake. Why not be proactive in your loved one's care. YOU get them the glass of water, or fluff their pillow. That would free up a great deal of time for the nurses to deliver professional care to patients who are in need of it. Just my two cents.

2343 days ago
4.

stopthepresses    

So... from reading his statement... the babies are going to be ok? I sincerely hope so. God Bless them.

2343 days ago
5.

jane doe    

The average nurse has only a Associate degree (Registered Nurse needs only a community college degree). A small percentage go on to get a BSN and even a smaller number receive a higher degree than that (masters or doctoral). The average pay for a ASN (associate degree) is $50,000 per year plus. Sadly, the medical profession is in trouble - more than just finding excellent nurses. To maintain their license they must maintain 15 continuing education units per year or 30 per 2 yrs. (that is not much when you consider it includes receiving units for CPR - a job requirement). So, the average nurse only needs about 20 units per 2 years (about 1.5 days per year). It is no wonder the nurses make mistakes, the requirements for a community college degree ( a 2 year degree) for individuals who earn a large salary, do not match up.
I am a RN - one who really takes the job seriously. I have over 27 yrs. of experience. 20 of them in trauma ICU/ER/life flight. I also have a Master's degree now working in private practice. Why - tired of nurses complaining of being under paid, over worked, and SHORT STAFFED!! Now - a nurse who could not read the label on the heparin bottle nearly Killed helpless babies! I wonder if she or he was paid >$50,000 with just a ADN. I hope they were fired and their license removed. There is no reason for this type of mistake. Drugs are serious business and should be taken seriously. I can't tell you how many times I overheard nurses complaining about how bad they have it but, could not be bothered to help their patients who help them with that high salary they are receiving.
Sadly, 40% of the nursing population is excellent, 20% is still growing, and the rest need new professions.
Time for patients to write the Consumers board of registered nursing and demanding a higher standard for nurses to maintain their license. Education is key! Next, get the unions out of the hospitals and help the colleges find educators (and funds) to increase the amount of nurses (qualified) to force those who spend more time complaining than working. If you can fire someone for not doing their job - you need to find someone to replace them. Increase the nursing pool and others will work harder at their job - including becoming more careful. It is up to the citizens to change this problem. Write your assemblyman, state senator, and governor. Be sure to also write the board of registered nursing.

2343 days ago
6.

LAME    

Good post Lori - my mom was a nurse for 40 years. I've heard lot's of stories. God bless nurses!

2343 days ago
7.

Connie    

There is NO excuse for not following proper procedure. I have several friends and family members in the nursing field, I'm not anti-nurse, but this was pure carelessness!

2343 days ago
8.

Nicole    

Working in the legal field there are only five words that come to mind ..... "successful medical malpractice law suit!". I certainly hope that all the medical personnel has their E&OE (Errors and Ommisions) Insurance premiums paid up to date and that the patients, start planning on how they plan on spending the money. Perhaps a trip, perhaps a home renovation but first, a trip to the court to file the appropriate pleadings and then, negotiations and a hefty settlement out of court.

2343 days ago
9.

Adam    

It doesnt surprise me one bit that this incident occured. I work in a hospital pharmacy, and can tell you that there are so many strengths to heparin its rediculous. The patients were lucky in this case were lucky.

2343 days ago
10.

Erik    

no excuse for this to have happened... i am glad that the hospital has agreed with this.

2343 days ago
11.

Patty    

Sorry Lori (1:23), but after seeing nurses screw up several times, notably killing my father by giving him food when he was not to have any due to a swallowing problem (aspiration pneumonia ensued on top of the pneumonia he was recovering from) and giving my recovering double brain aneurysm mother pills when she was never to have them as she could not yet swallow and having her end up in the ICU after vomiting the pills into her lungs, I have no love for nurses.

They may be overworked and they may be rushed but that isn't our fault. If they can't adequately do their jobs, read the charts and instructions, and be sure they are correct, then they shouldn't be in the health care field.

I don't trust ANY nurses and I double check EVERYTHING they do. My parents are gone because of lacksidasical care and these babies could have been gone as well due to nurses rushing around and not following procedures.

Our little jokes may be a waste of your valuable time but your big mistakes could be a waste of our valuable lives!

Obviously this isn't aimed at you but just a general response about how nurses screw up all the time and how my family and I have been victims of it. It's bad enough that bad things happen to good people but when a nurse is too rushed or whatever to make sure he or she is doing the right thing and causes a death or a near death, I say fire him or her before it happens again. I certainly hope this hospital got rid of the nurses who did this to those babies and other patients.

2343 days ago
12.

ty    

I have worked in hospitals for 25 years in many positions. The problem with nurses is that they are not focused on what they are doing all the time. I have seen orders for 600 mg of morphine, not 6 and if a good unit secretary doesn't catch it, the pharmacy will. The problem Lori with the call bell, is that it takes too long to get answered. When I called that I had to go to the bathroom and couldn't because the IV was hanging from the bed pole that I couldn't reach, I waited 25 minutes. Only when I told them I would have to pee on the floor did someone come in. When the hospitals changed to primary care instead of having good nursing assistants helping everyone, they did the patient a disservice. When I tell someone that a patient needs help I often hear "it's not my patient" . Only when someone realizes the patient is trying to climb over the bedrails do they get up to help. Nursing is a hard job. It really is. But being bothered is a big part of it. People don't just give water without clearing it first. Part of the professional care is doing those little insignificant things as well. I could tell stories that would make people's heads spin and it would serve no good purpose so I don't. At a higher level , perhaps the manufacturers could redo their labeling to indicate this is an unusually higher dose...much like windows, "are you sure" box. Another med that is often given at higher doses for the same reason is Insulin. The vials have small writing and perhaps some kind of color coding would help. In this instance, the concerns aren't about all nurses, but this one.
Truth is, the nurses are so bogged down with data they don't care a whole lot about getting you a graham cracker and some juice in the evening.

2343 days ago
13.

Brenda Renae    

I am a practicing Critcal RN and have been for 21 yrs! I have traveled around the US for 11of those years! I have worked very hard and very long hours! I work mainly in ICU's, Burn units, Trauma centers, and Large teaching facilities and small private institutions. I truly love taking care of the very ill! I truly care about my clients as if they were my own family member. I am really good at it! I am patient, I am careful, I am compassionate, I am knowledgeable, I respect people of all cultures, socioeconomic backgrounds! AND..Next year, I QUIT!!!!!!!!!!!!!!!!!!!!

And it is people like that Patty that are the reason! Sometimes Family members, in their quest to be helpful, actually harm the person they most care for, by alientating, those of us who have the SKILL and the EXPERTISE to help their loved ones recover! I am not saying that we don't deserve the criticism when we make a mistake. But if we were respected and supported by Family and Management and Society, maybe our stress levels, when we are hurrying around trying to make everybody happy, help our fellow staffers, care for our clients, their families (With their "Drama among themselves") we could take a time out more often and mistakes and errors would be less! There is NO WAY, mistakes are not going to happen! But the fact remains that Nurses are pushed to the limit and most times when we are given and Press, unfortunately, it's when a mistake has been made! There is a NURSING shortage! We need to support nurses any way we can! And I am so sorry about your lost Patty! But if society as a whole does not do what we can to increase the number of qualified nurses, instead of complain...................the future looks bleak for when we are the client! First, Respect US! We are not your Beck and call girls/guys, we are qualified professionals, who worked hard to get through a "Gruling" Nursing program! PAY NURSES MORE MONEY! Yeah, I said it! Of course, we can't expect to make as much as pro Football players or pro Hockey players....come on we just help in the hospitals, saving lives, no biggy, not like winning the Superbowl or anything! Because you see, new nurses arn't staying very long in the profession, too many better paying options! And us baby bommers are getting too old! Pay more attract more nurses! More help, less stress, better care, happier families! Otherwise, Patty, keep your family , yourself at home when you/they get sick and YOU take care of them!!! Let me know how that works for you!

2342 days ago
14.

Pat    

God forbid you bother a nurse when you need something !! The Nurses association complains there is a Nursing shortage, how dare they? There are PLENTY of RN's out there, they just DO NOT want to do anything but chart & meds. I have been in the healthcare industry for over 30 years, and MANY are "workers", but TOO MANY others just want to sit & delegate to others. Yet these are the ones who claim of being over worked,and not being paid enough. Anncilary staff can have as many as 18 patients to tend to, while the RN has 4-6. It's ALL about numbers in the hospital, and PRODUCTIVITY. The most amount of work the CEO can get out of the LEAST amount of staff. JCAHO has standards to follow, but this IS only done when the hospital KNOWS JCAHO is coming for an inspection. Suddenly everyone has less to do,and less patients to care for. AN error like this one MAY have been prevented if the Nurse/Nurses followed their hospital policies, and perhaps did medication administration more frequently?

2342 days ago
15.

Sandra    

Love to read the comments here. I too have been a nurse for 16 years...These types of mistakes happen...they are terrible to the family and the staff. It is never our intention to hurt anyone. Glad it has worked out and seems that the twins will make a full recovery.

as for the call bell....let's face it, they are an important safety feature. But to all you nurses on here...I hate it when the little old ladies ring it because they are lonely. That's a waste of time. I agree..families should be more involved..some are...get them water,wash thier backs even. I think what people need to realize is I don't just advocate for you....I have 6 or 8 other patients to worry about...your hemrriods don't really concern me at the moment when I have 3 people dying down the hall of cancer and they are palliative. That drives me crazy...you wonder why It's taking me so long to answer a call bell....maybe I am grieving with a widow who has just lost her spouse of 60 years....the pillow fluffing will have to wait......sorry.

We are held accountable....we all pay are dues,maintain our license and re-educate annually. But....in the end we are human,thank goodness this error didn't end in a death. I would imagine this nurse will possibly loose her job.

no one wins here. Thanks for reading......to all you great nurses out there...have a great shift. :)

2342 days ago
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