A citation has been issued against Cedars-Sinai for a massive medical mix-up that injured three newborns, including the newborn twins of actor Dennis Quaid.
The L.A. Times is reporting the California Department of Public Health found the hospital failed to "adhere to established policies and procedures for safe medication use ... These violations caused, or were likely to cause, serious injury or death to the patients who received the wrong medication."
The twins recovered and are home.
The report also indicates the hospital's practices "created a risk of harm for all hospital patients." According to the report, hospital staff and nurses failed to check labels before they administered the drug to the patients, including the Quaids. They also did not maintain proper records of the medication that was used, even though there were already policies in place to prevent this type of mistake from occurring.
Kathleen Billingsley, deputy director of the Center for Healthcare Quality, tells the Times the public health agency has not yet decided whether to fine Cedars-Sinai for the error.
The Quaid twins were twice given 10,000 units of the blood thinner heparin, when they should have received 10 units. The report indicates two pharmacy technicians mistakenly stocked the cabinet with adult dosages of the drug. The nurses involved told inspectors they could not remember whether they read the label on the heparin vials or not.
The third child who also received the overdose did not require further treatment and was released the next day.
In a written statement to the Times, Cedars chief medical officer Dr. Michael L. Langberg said, "While this is a rare event, we are pleased that the [public health department] shares our view that it is an important opportunity for the entire institution to explore any and all ways we can further improve medication safety." He also said "Each of us is personally responsible for patient safety."
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Reader Comments
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Good. This was a completely avoidable error on the nurses part. It didn't have to happen.
Someone wasn't paying attention
This story just scared me so much.... Any parents worse nightmare! Angels watch over these babies!
The hospital and medical staff administering the medication is completely at fault. After all they completely ignored their patients five right of medication administration. Right Patient, Right Medicine, Right Dose, Right Route, and Right Time. Had the even taken these basic steps taught to any medical and nursing student, this would have never happen.
This shows how stupid and anti-big business Quaid and his ill-advised lawyers are! Instead of going after the hospital and their bad protocols, but then is it not always about accountability!
let scroll up, im sure theres an uplifting story coming any second!!!
Between the Dr. Phil incident with Brit and now this, you really wonder how this hospital is in business, Their patients and the legal rights they owe the patients obviously mean nothing to them! Glad I don't live near there....I'd be demanding you transport me elsewhere! I hope Brit and the families of these newborns take them to the cleaners!!
WOW TMZ finally figured that out?
Unless they went in and administered the drugs themselves, who else could it be at fault????
Thanks for clearing that up, I thought these two newborns tried to bleed themselves out intentionally.....
And as for if they're OK, you do understand the hep is out of their system and they are at home, right?
isn't this the hospital that failed to comply with HIPPAA and privacy with Dr. Phil barging into Britney's room. This is very concerning that a medical center is exploiting there famous customers, imagine what it is like for us regular patients!?
As a nurse and particularly a nurse that works in the NICU, I myself have made errors. It is unfortunate that it happened to a celebrity's child(ren), that is the only reason the Cedars would be making a statement about it. These things happen and unfortunately they happen more than you think. It's called a sentinel event and they happen so much that hospitals have sentinel committees that work and investigate these type of errors.
13. As a nurse and particularly a nurse that works in the NICU, I myself have made errors. It is unfortunate that it happened to a celebrity's child(ren), that is the only reason the Cedars would be making a statement about it. These things happen and unfortunately they happen more than you think. It's called a sentinel event and they happen so much that hospitals have sentinel committees that work and investigate these type of errors.
Posted at 10:33PM on Jan 9th 2008 by NICU RN
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From your prespective a nurse, what changes do you think need to be made to avoid future errors?
