Full Statement from Cedars-Sinai

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.

Reader Comments

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1. 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.,

Posted at 11:22PM on Nov 20th 2007 by liz

2. 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!

Posted at 11:39PM on Nov 20th 2007 by martha

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

Posted at 12:18AM on Nov 21st 2007 by My Prayers with These Babies

4. 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.

Posted at 1:23AM on Nov 21st 2007 by Lori

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

Posted at 1:58AM on Nov 21st 2007 by im just saying

6. 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!

Posted at 2:15AM on Nov 21st 2007 by Me

7. 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.

Posted at 4:11AM on Nov 21st 2007 by Patty

8. 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.

Posted at 4:46AM on Nov 21st 2007 by ty

9. 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?

Posted at 7:36AM on Nov 21st 2007 by Pat

10. 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. :)

Posted at 8:27AM on Nov 21st 2007 by sandra

11. I am an RN and have been for 13 years. I no longer will work in a hospital. I prefer to work in -outpatient settings because of the BS that goes on in the hospitals. Nurse-patient ratios are too high in most hospitals and most hospitals have gone to primary nursing. Primary nursing, for those readers who aren't familiar, is where one nurse is responsible for every need that all of his/her patients might have. That nurse admits/discharges patients along with all of the necessary paperwork (which must be RIGHT or you create liability for the hospital as well as yourself...God forbid you leave out an allergy and the patient experiences a reaction to something...so it takes time for the paperwork) passes all the medications (which are spread all throughout the day), do all the dressing changes, starts all the IV's, draws many of the labs, performs the 12 lead EKG's, inserts/discontinues foleys, changes medication tubings, mixes his/her own drips, and in the evenings or weekends or just when short staffed (which is always) does physical therapy (which is usually walking the patients in the hallway) and the CNA jobs of making fresh beds and giving sponge baths to the patients, because half the time you don't even have a CNA to take vitals, do blood sugar checks, change beds, give baths and fill water pitchers. In between getting pain medicine, bringing/taking out patient trays, helping them into chairs, getting extra pillows and refilling water pitchers. Add to this the patients who need blood, which requires trips to the lab, calling doctors, charting on every patient and continually assessing patients with frequent checks just transferred from other units. In one hospital I was told that the RN's would start doing the respiratory treatments also so that the hospital could save money. Keep in mind that there is a severe nursing shortage so you could be assigned 8 or 9 patients on a day shift and up to 15 on a night shift. Not only am I morally and ethically responsible for these patients, I am also legally responsible. Unlike the CNA's, etc., I can actually, just like a doctor, be sued for malpractice. So you better believe I prioritize care. Charting (to protect myself and the hospital) comes before getting you a glass of water. Hospitals have lost nurses because we are not super heroes and mistakes will always happen because a) we are human, just like you and b) we are asked to do too many things all at the same time, which is NOW. Unlike you who are not nurses, when you maybe make a mistake by not paying a bill on time or maybe enter a number wrong in a data sheet at your work, our profession deals with people's lives so, yes, the repercussions can be far more serious and lasting. But until things change in the hospitals things will only get worse and nurses will stay away. All you will be left with is new grads eventually. The whole healthcare system is to blame as well as for-profit mentality. When that changes and shareholders don't dictate the bottom line of the hospitals, maybe the hospital administrators will be free to staff the hospitals how they really should be staffed.
Thank you.

Posted at 8:50AM on Nov 21st 2007 by Kat

12. My experience with nurses comes form the 6 days my son spent in the hospital this summer recovering from a serious virus. While I appreciate the work nurses do, it seemed to me that their major function was taking vital signs and giving medication at the required intervals. Everything else, you have to ask for or it will not be provided. Therefore, they should be able to get it right and not just reach for a medication without reading what it is they have grabbed off a shelf and then administer it and use the excuse that they were distracted by people talking to them and asking questions. What is the excuse for leaving an IV in a persons arm for more than 3 days and giving them phlebitis as a result? That's what happened to my son and when hot compresses were prescribed by the doctor, they gave him this hard, portable paper heat bag that got mildly warm for about 5 minutes. Upon giving him the bag the nurse said, "it's the last one I have so make it last". I managed to scrounge around the room and found some super strong paper towels that I wet with hot water in the bathroom and gave that to my son to relieve the pain of the condition they caused, yet were unable to properly treat. It's a disgrace.

Posted at 8:51AM on Nov 21st 2007 by PR

13. Careful Lori, your disdain for patients ("your little jokes are a waste of our valuable time")is showing. You might be happier doing something else.

Posted at 9:00AM on Nov 21st 2007 by Phil

14. In response to Lori...
I work in healthcare for a hospital at an outpatient rehab facility, although I am not a nurse. I understand where you are coming from, but patients come first. No patient or family member should be considered an interruption. The reason patient's family members interrupt you is beacuse nurses are NOTORIOUS for not answering call lights in a timely fashion, they are usually too busy talking amongst themselves. Nurses may be overworked, but they are paid good money and should know what they are getting into when they go into that profession. I have met some pretty incompetent nurses, and I seriously wonder how they ever made it through school. It is pretty scary when an RN can't read an EKG, but yet I am not a nurse, and I am extremely competent in EKG's. I hope I am never in a situation where I am hooked up to an EKG monitor with a nurse like that.

Posted at 9:29AM on Nov 21st 2007 by DMG :-)

15. Only the nurses keepinng bringing up the water issue but to comment on that I have had several family members in the hospital and have asked where to get ice,juice etc. for the patient and was told that I wasn't allowed to get it.
And when we are admitted to the hospital we are paying for 24 hour care why should a family member have to do the job that someone there is getting paid to do.
as for Lori you sound as if you have a bad attitude and you would never be my nurse.

Posted at 9:33AM on Nov 21st 2007 by ha

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