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Full Statement from Cedars-Sinai

Posted Nov 20th 2007 10:26PM 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.

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(Page 3 of 4) Previous 15 Comments | 1 | 2 | 3 | 4 |

31. I hope that there will be some sort of recourse against that particular employee, but on the same note, my son was in the NICU for 3 weeks with miconium aspiration and received the absolute best care I have ever seen. the thing we all have to remember is that there is a reason why it is called a "practice" but we are all human.

Posted at 11:00AM on Nov 21st 2007 by Morgan

32. I would have to tell one story that broke my heart, My mom had surgery and 2 days after the surgery she was given a high dose of a med threw her IV that put her into res arrest she was given a med that she never needed it was a mistake, she was put on life support and wheeled into the ICU, i sat with her day in and day out. there was one evening when she started chocking and was turning blue, all the alarms went off and no one came in, when i ran out to the nurses station to which was right out her door sure enough there were 3 nurses sitting there drinking coffee, when i screamed for them, Her nurse stated, ( i CANT EVEN GET A CUP OF COFFEE IN ), and slowly got up to help me mom who by then was blue all over and her heart rate was 160, the nurse succtioned out my moms tube that went down her throat, and as she walked away stated to me that i should learn how to take care of matters like that, She disrespected me and my mom in every way that night, I called the cheif of staff in made a formal complaint it went into a meetings with all the hospital ad, then i contacted a laywer, thankfully the other two nurses testified on my moms behalf, even tho they actually could have help at the time , but the nurse lost her licenese and is no longer able to practice nurses in the state of MA, now my oldest daughte had surgery 5 times at a childrens hospital and she did get the best care her nurses are like family, to this day whenever my daighter is admitted they all come to see her, one bad nurse dont make then all bad, i do have great respect for nurses and dont know how i would have ever go threw my daughters heart condition with out them

Posted at 12:09PM on Nov 21st 2007 by pamela

33. I was in a top CA hospital last may for Major surgery. My stay was in the ICU. The call buttons did not work, the nurse did her work from a computor and only checked on me when she said I pulled my tubes out. They would not let my daughter in to help with me, only at visit time. I got no water, clean bedding, etc. I found out that the hopitals are hiring nurses from other countries due to the shortage. I saw them standing around talking. I now know that when I have another problem, want it in writing that my daughter can monitor my situation and if they are not doing their job, go to the person above them.
I will not go back to this hospital even though they have the best specialists.
We need to do more to keep and get more good nurses. Them if they can't do a good job, get rid of them.

Posted at 12:40PM on Nov 21st 2007 by Janet L

34. I have been a LPN for 6 years and I work at a hospital on a medical/surgical floor. I do agree that this situation WAS preventable...but I understand how it happens. It saddens me to think that some of the public has such a low opinion of nurses. I must say though, the general public HAS NO IDEA what goes on in any given shift. Let me give you a quick rundown as to the six patients I will most likely take care of tonight (like most nights) pt. 1 is a 60 yr smoker who can no longer breathe and will call out continuously due to anxiety (family could sit with pt and calm them), pt 2 is an alzheimer's pt who was basically dumped in the ER by family because they could not handle them anymore. Though I understand their aggrevation, I do not understand how they never come back to visit. I will spend 1/4 of my shift chasing this person out of other pt's rooms. pt.3 is an inmate who constantly calls out to complain about the food. The guards stop me frequently to use the phone to call anyone, because they are so bored. pt.4 is an alcohlic who screams all day at imaginary cats, throws his food across the room, and attempts to punch, kick, or bite me whenever I apporach him. Pt 5 is a "frequent flyer", a pt that comes back over and over. This pt has "abdomminal pain" that somehow is never caused by anything and is ONLY relieved IV Morphine or Dilauded every 1-3 hours. And I do mean every 1-3 hours. Pt 6 is YOUR family member, someone who is most likely very ill and or just had surgery. This person needs MEDICAL care, which is what I am here to provide. Due to imaginary cats, roaming pts, waiting on the inmate who believes this is a restaurant, attempting to make someone breathe that has no lungs left, and giving narcotics to someone that really doesn't need it, I have almost no time left for YOUR family member. This is the person I think about all the way home after work. This is the person I think about before I go to sleep. This is the person I vow to take care of today no matter what. Until the cats come back.

nurses are medical professionals that provide MEDICAL care. The sad reality is that Most of the care provided is nonmedical in nature. We are paid well because we have a stressful and dangerous job that not many people can do. When I go to work today there is a real possibility that I will be assulted or contract a fatal disease. What's the worst that will happen at your job today??

Posted at 12:12PM on Nov 21st 2007 by K,LPN

35. I have been a nurse for 30 years and I would like to tell you how many times I could not go to the bathroom, too busy, could not eat lunch, too busy, not have a break in 12 hours, too busy. I am not defending lazy nurses but I was a good nurse and because of my work ethics was always exhausted. I no longer and have not worked in a clinical area for years. I chose to do other things because I knew I would not last working as hard as I was working. As a result of my nursing career, I have a chronic back condition that causes me pain every day. An on the job accident. I have slipped on floors that were wet twice, breaking an arm on time and a rib and arm the second time. This was from coffee that was spilled onto the floor. I have a positive PPD for TB and have Hep B antibodies. All from patients. If I ever need massibe doses of steriods I may get both of these diseases because even though thery are "dormont", I have still been exposed. Right now I am teaching nurses at a community college. I hope I instill good work ethics along with my teaching. But please remember folks, there is not a clinic, doctor's office, skilled nursing facility or hospital that can run without nurses.

Posted at 1:11PM on Nov 21st 2007 by f bell

36. Nurses can be very careless. After all it's not their loved ones they are nursing! In 1970 my 3 month old son had a lung infection & the room across the hall had a teenage boy that had a staff infection. There was a big sign saying to wash hand before & after entering his room ,but did they? NO! My baby got the staff infection and was dead within 34 hours of entering the hospital. I know several nurses who are dedicated to their patients and treat them as family, but the majority are there for the money only. I hope and pray Dennis Quaid's twins survive without any after effects. My prayers will be with the Quaid family as well as the other families that endured this horrible ordeal.

Posted at 1:31PM on Nov 21st 2007 by Connie G.

37. Lets all slow down. Did the nurse make a mistake? Yes, she/he should have read the label before using the drug. did the pharmacy tech make a mistake? Yes. She/he should have read the label and supplied the correct drug. Did the company who makes the drug make a mistake? yes, they should have used different colors to indicate adult vs. pediatric dose. This, by definitiation is a systems failure and the response should be to fix the system problems. When we blame and punish we push these types of mistakes under ground. This should never have happened so lets make sure we all work together to ensure that it becomes hard to make a mistake by making sure that the systems are as close to fool-proof as we can.

Posted at 2:14PM on Nov 21st 2007 by barbara

38. Penny,
You said it is time for nurses (I presume) to stop multitasking and pay attention to the problem at hand. So...if you are in the understaffed hospital and I am your nurse and both you and another person are having a true medical emergency....who should I give my "undivided" attention to? If I suction your ET tube so that you can finally breathe should I ignore the person next to you who I think is exhibiting signs of a stroke? Nurses are REQUIRED to multitask today by essence of understaffing. If we didn't, how do we choose which task to prioritize when they are all equally important?
I assume by human nature most of you out there would prefer we attend to you or your family first.
It distresses me that people have such a misconception about the true nature of nursing; it makes me so glad that I moved off (along with my extensive experience, unfortunately) to the outpatient realm. Why kill ourselves when we are subject to such attacks? When we all go away because we are tired of the blame and attacks where will all you people be who need competent and caring nurses? We will be taking care of our own family members in the hospitals to help out our family member's nurse....who will be taking care of you and yours? Scary thought....

Posted at 2:16PM on Nov 21st 2007 by Kat

39. Kat,

you moved to the outpatient realm, while I left nursing entirely, largely for the same reasons. Continuing hospital cutbacks and being told shift after shift to do more with less left me crispier than a bucket of KFC. So I walked away.

The nursing shortage is more than just fewer students and more retirees, America. Wake up.

Posted at 7:20PM on Nov 23rd 2007 by No Longer An RN

40. WHAT DOES IT TAKE FOR THE AMERICAN PEOPLE TO SPEAK UP ABOUT OUR LACK OF HELP IN HOSPITALS? THE HOSPITAL ADMINISTRATIONS ARE CUTTING BACK ON PERSONNEL SO THEY CAN MAKE MORE PROFIT. IT DOESN'T STEM FROM THERE; TRY GOVERNMENT REGULATIONS AND COST OF SUPPLIES... TO SAY NOTHING OF WHAT INSURANCE WILL PAY AND WON'T PAY... IT HAS TO STOP! WHEN AN INDIVIDUAL IS ADMITTED TO A HOSPITAL THEY SHOULDN'T HAVE TO WORRY ABOUT THE CARE THEY'RE RECEIVING WHEN THEY NEED TO REST. THE FAMILY SHOULDN'T HAVE TO BE FRIGHTENED OF LEAVING THEIR LOVED ONE ALONE FOR ANY LENGTH OF TIME IN CASE THEY NEED SOMETHING THAT A NURSE WILL NOT DO FOR THEM. SHAME ON YOU, AMERICA!!! SPEAK UP OR SHUT UP!!!

Posted at 4:27PM on Nov 21st 2007 by nlm

41. also to Lori, explain why 90% of nurses are so big. I'll tell you, they sit around eating donuts or whatever other crap they can get their hands on, usually from their friendly pharma rep, so they sugar crash all day and all night. That is why they feel so overworked. Seriously everyone, think about it, most nurses are FAT>>> Quit eating so much crap and lose a few.

Posted at 4:42PM on Nov 21st 2007 by sheri

42. I can't believe all of the excuses being given here. It's not an easy job (far from it & mistakes will happen), but it's easy to double check a medication. I'm sorry, but if you're too busy to read a bottle...find a new profession, because these are lives, not happy meals!

Posted at 5:31PM on Nov 21st 2007 by Me

43. I cannot believe the arrogance and sense of entitlement that is emminating from health care consumers in this day and age. As one of the wealthiest, most educated nations in the world one would expect a consumer of health care to be as well read as if buying a new plasma TV or BMW. We all know that if we are investing in that $25,000 car we read all about it, know every little feature not to mention the upgrades. But then when it comes to any sort of health care Americans cry ignorant, mal informed, victimized! That is disgusting. Take responsibility, become informed. In this technology saturated millenium there is absolutely no excuse. Please do not even try to debate my statements with a lame defense of "well when we need a doctor, hospital or nurse it's usually unexpected". Really?? Lame lame excuse. We all arise in the morning, get into a motor vehicle, and for those crazy enough to live in LA venture out onto some of the worst driving conditions. We are all aging, and with aging comes diseases of all sorts. PLAN AHEAD!!!! I respect the medical profession for dedicating their time to the not only initial education but the ongoing necessary education. Plus the 12-14 hours a day that is given in patient care.
Medical professionals are not hand maidens as once they had been. Nurses are university educated, making decisions 12 hours a day. Dealing with life threatening situations. Not coffee, tea or cold beverage?? Not paper or plastic? Here or to go!!!! But situations where they are administering medications and treatments that could have fatal outcomes. One more thing....The hospital is just that, for sick people to recover. Not some hotel to accommodate guests.

Posted at 12:35AM on Nov 23rd 2007 by Michelle

44. I have been a RN for 21 years. This is tragic error as usual the nurses will hang. No one is even concerned about the pharmacy error that put every single patient on that unit in danger. I hope the pharmacist who released a life threatening medication to be delivered in appropriately to the floor is also disciplined. That is where the error began. Who found the error and stopped further damage? I am betting a nurse. That is who saved more patients from harm but that will never be recognized.

Posted at 5:32PM on Dec 2nd 2007 by camerashyn

45. Jane,
You speak as a nurse who in 27 years of practice has never made a human error. You come off as being arrogant and I suspect that the reasons for your leaving the hospitals go deeper than what you purport.
There is a reason that the famous phrase exists...."nurses eat their young". If I had a mentor that had your attitude I would rethink joining the profession.
By the way, the requirements for retaining nursing licensure varies from state to state. Some states require absolutely no CEU's...and others require much more. I am all for continuing education. You are of the generation that discriminates against other nurses due to their origination of education. My mother, in the 1960's, obtained a 3 year nursing diploma, I attained a BSN, and I work with some ADN's that are far more experienced than many BSN's and I would choose them to care for me over those BSN's. I even know some long-time LPN's that are more experienced than some BSN's. It is all individual.

Posted at 7:07PM on Nov 23rd 2007 by Kat

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