Many of us recall that Dennis and Kimberly Quaid went through a medical malpractice nightmare involving their twins back in 2007, but I was compelled to revisit what happened to the Quaid twins, and to discuss new ideas on how to prevent medical malpractice and nursing/hospital mistakes in the United States. A series of every category of medical malpractice error occurred in combination to nearly take the lives of Dennis and Kimberly Quaid’s twin sons in 2007 very soon after their birth at Cedars-Sinai hospital in Los Angeles.
The twins were supposed to be administered a routine anticoagulant called hep-lock for a staph infection that both babies developed immediately after birth. This required nursing staff to set up an IV and administer antibiotics along with the hep-lock to prevent blood clotting. Unfortunately, due to several hospital errors including nursing mistakes, the nurses administered at least two doses of heparin, an anticoagulant manufactured/sold by Baxter Healthcare, that is 1,000 stronger than hep-lock (essentially hep-lock is 10 units, and heparin is 10,000 units). When the Quaids returned to the hospital after getting a few hours of sleep, to check on their babies, they were met at the hospital by Risk Management personnel and lawyers– the truth about the mistake had been concealed from them for at least eight hours if not longer. The massive overdose meant that the babies did not have their natural immunity to clot blood and even the slightest opening in their body caused blood to spurt out and on one occasion blood spurted from one of the baby twin’s umbilical cords literally across the room onto the wall. Dennis and Kimberly Quaid went through almost two days of their babies’ lives hanging in the balance before they slowly recovered and regained the ability to clot blood again. They recounted their stories in personal interviews aired on 60 Minutes about medical malpractice and their newfound mission to prevent medical errors in hospitals.
Medical malpractice affects all: Rich, poor.
While the Quaid twins were hanging on and trying to be stabilized, the Quaid’s pediatrician advised Dennis and Kimberly Quaid that the mix up of the hospital/nursing staff with regard to heparin had also occurred within the last year in an Indianapolis hospital also. The manufacturer of both of the medications, Baxter, was aware that six infants had all been given their wrong medication (vials of heparin, rather than hep-lock vials also sold by Baxter) with the result that three babies at the Indianapolis hospital had died. Upon hearing this information, Dennis Quaid did further homework and was amazed to find out that Baxter, the pharmaceutical manufacturer, knew that heparin and hep-lock medications (in bags or vials) were labeled similarly in appearance and blue text/color on the vials, and that a rushed nurse or medical staffer could easily mix them up.
Note the similar appearance of Heparin and Hep-lock when the Quaid twins were overdosed:
After Heparin re-labeling to distinguish Baxter Heparin vials by color:
However, Baxter had never issued any type of actual recall of the products and the similar blue color Heparin and Hep-lock medication labeled vials were at Cedars-Sinai Hospital when the mix up occurred there. Baxter had issued a written warning to hospitals but left the products as they were at hospitals around the U.S.A. Quaid not only decided to bring a medical malpractice lawsuit against Cedars-Sinai Hospital, but the Quaids were motivated to sue Baxter for a variety of errors that they claimed would have prevented the massive overdose to their baby twins-including a recall.
The Quaids settled with Cedars-Sinai Hospital and Dennis Quaid has stated that "we didn’t want to sue the hospital because we need really good hospitals…. and as part of the settlement, Cedars spent millions – on electronic record keeping, bedside bar coding, computerized physician-order entry systems-to improve patient safety. I have to commend them for that." A hospital spokesperson, Simi Singer, also stated later "we began additional focused education on medication safety and have implemented additional procedures and protocols for our pharmacy and nursing staff." Subsequent analysis of what went wrong indicated that a medical staff person had sorted heparin and hep-lock into the wrong drawers or storage locations, and then also nurses did not clearly check the vials before they were administered. Last, the Quaids still have a pending lawsuit that they are seeking to settle against Baxter for a variety of acts that the Quaids assert were negligent.
Dennis Quaid’s mission is to improve the hospital, and nursing system to reduce or prevent human medical error. However, Quaid has stated that he is suing Baxter because Baxter did nothing to recall its products even after Baxter learned that babies died because of medication errors where nurses applied the wrong medication-both Heparin and Hep-lock were sold by Baxter in similar looking blue text small vials. In fact, Baxter spokespersons’ have publicly stated that Baxter changed the labels on heparin and hep-lock after the Qaid twins overdose occurred to make them completely distinguishable. However, Baxter claims no recall was issued because there is a duty on the hospital staff to properly read labels and therefore Baxter is not legally responsible to the Quaids. Accordingly, Baxter denies any fault. Quaid has stated in interviews that he is astounded that regular consumer products such as dog food are recalled but no mandatory drug or pharmaceutical recalls are mandated in a situation such as what occurred with his twins. Also, Baxter is defending against the dangerous drug case seeking legal immunity because the FDA approved both Heparin and Hep-lock and their vial labeling. Baxter claims if it received FDA approval, the suit must be dismissed under a complicated but often raised corporate defense called “federal preemption” immunity.
As Quaid testified before the U.S. Congress in 2008, Baxter is defending his medical malpractice related lawsuit on the simple argument that its drug/medications were earlier approved by the Food and Drug Administration (FDA) and therefore Baxter is immune from answering for its labeling inadequacies. Quaid spoke out before Congress on the unfairness of this federal preemption/immunity defense to lawsuits that has been embraced by many federal courts, including the U.S. Supreme Court in an earlier lawsuit not involving Baxter or its medications but involving medical devices.
Quaid also attacked anti-consumer laws including one in California which set a cap or ceiling on the amount of damages a family could recover for medical malpractice. Many states, including Virginia, also have medical malpractice caps which set an artificially low recovery amount on medical malpractice lawsuits – singling such suits out for caps or ceilings where other types of negligence lawsuits have no such ceiling.
Quaid takes action to reform and prevent medical/nursing errors.
As of 2010, the Quaids’ twins are doing fantastic according to their proud parents. Give Dennis Quaid credit for not standing by and remaining silent – instead he has become a patient advocate for prevention of medical and nursing errors. In 2008 the Quaids formed the Quaid Foundation which called for hospitals to adopt bedside bar coding, scans on patient’s wristbands to match scans on medications and other improvements so that the wrong medication does not go to the wrong patient. Since that time, Quaid has teamed with Charles Denham, M.D., a leader in the patient safety movement who founded a nonprofit Texas institute called Texas Medical Institute of Technology (TMIT) which test systems and promotes healthcare safety. Quaid narrated a series of documentaries about preventing medical harm and hospital errors and malpractice. One of the documentaries is called "Chasing Zero: Winning the War on Healthcare Harm" which is available at www.safetyleaders.org and discusses medical error victims, interviews actual medical providers and nurses who have made mistakes and are calling for reforms.
One compelling story involves Julie Thao a nurse specializing in obstetrics with over 20 years of nursing practice. She made a tragic error involving an IV bag which looked identical to a different antibiotic bag which ended up being the cause of an overdose death to the mother, who was in labor, although the baby survived. This nursing error caused Thao to become suicidal but eventually she bounced back and was offered a position with TMIT and now she is a speaker around the country at healthcare safety conferences discussing how to improve the system and avoid medical malpractice errors, especially involving nurses and hospital workers. The TMIT Foundation/Institute has a new publication called The National Quality Forum Safe Practices For Better Healthcare which outlines 34 steps that can be taken to reduce medical malpractice and hospital errors. The ordeal that the Quaids went through absolutely emphasizes that medical malpractice picks on the rich and the poor with equally random victims. It can strike your family, it can strike the families of nurses, doctors, or any other person. However, if it takes a celebrity and movie star like Dennis Quaid (and his wife Kimberly) to focus the public on the need for improvements in the delivery of medical and hospitals services to the public, so be it.
To learn more about the Quaid’s battle with medical malpractice laws, check out this article.
About the Editors: Shapiro, Cooper, Lewis & Appleton personal injury law firm (VA-NC law offices ) edits the injury law blogs Virginia Beach Injuryboard, Norfolk Injuryboard, and Northeast North Carolina Injuryboard as a pro bono service to consumers.
james O'Hare RPLU AIC AIS
Very scary for the parents. The Quaid's did accept several million dollars in settlement, despite their claim that they want "really good hospitals."
This was a publicity settlement,for their 2 days of worry, not a damages suffered by the twins settlement. There could have been horrible damages to the twins, but there wasn't. There was liability , but no damages caused by the liability.
The publicity and Baxter's changes will help others. Bar codes may help, unless someone gets the wrong bar code. The problem always and usually comes down to poor staffing, concentration issues, change of shift communication shortfalls and fatigue. Fix that.
Better staffing eliminates many of the problems causing med mal. Unfortunate,that we are a reactionary country and not a pre-emptive country. Assigning more nurses, another great idea that will never happen. Certainly cheaper than paying the Quaid's the equivalent salaries for dozens more nurses at Cedars.
As an aside, in 25 years of med mal claims, I have seen more than 18 different types of medication errors. All fatigue, communication or concentration based.
VP med mal claims Physicians Ins Co Pompano FL.
Jim: As always, thanks for reading our blog articles and for your incisive comments too. While we are on opposite sides of the aisle, the idea here is to exchange health and safety knowledge that may serve to avoid medical malpractice errors in the future.
I agree with Jim. Better staffing can alleviate many errors. Hospital nursing is one of the most difficult jobs on the planet. Unfortunately, meeting the "standard of care" happens by sheer accident, in many cases. Having worked in quite a few hospitals, I have only found one where I consistently felt safe to practice.
I chose to leave nursing because it is virtually impossible to provide good, holistic, patient care. Someone always gets the short end of the stick. Unfortunately, when errors occur, and we ask if the standard was met, we look at the incident as if a provider had nothing else going on in that particular moment.
In regards to the heparin incident. There is really no excuse for not reading what medication you are giving when you are calm and alert. But, I can easily see how an overworked, tired nurse, took for granted that the hep-lock was always in the same place.
It is a sad world we live in when we place such a high standard on health providers (almost to the extent where no mistake whatsoever is permissible), but then we fail to give them the tools needed to even have a chance at meeting the standard more often than not.
My point is that the actual "standard of care" has become substandard in practice. Scary. Unfortunately, I am still working as nurse until I find legal employment, and then I hope to make it a personal quest to help change the healthcare delivery environment. People really should be afraid of what the future holds if things don't change.
Thank you for this article and summary of the facts of this tragic case. I agree with the comments of previous contributors above but would like to add additonal thoughts for consideration. While fatigue and short staffing are paramount contributors to errors, there are a couple of others I want to toss out. Interruptions in the flow of work and an individuals' concentration occur moment to moment without appreciation for how it impacts on a possible error occuring. When your train of thought is interrupted, your likelihood of error increases expoentially. Secondly, our society has prized the ability to "multi-task" when the brain is not designed to process many inputs while acting on items simultaneously. Third, we trust our ability to recognize patterns repeatedly and thus do not cross check the reality to verify it to be true. Case in point the comment that the HepLock was always in a particular location. Over confident about ones experiece as a guide, coupled with trusting patterns repeat themselves contributes to errors occuring.
After many years at the bedside and in leadership positions in hospitals I have learned to value how important these factors are and now seek ways in which I can sensitize others to the impact in avoiding other tragedies like the one described with the Quaid babies.
james O'Hare RPLU AIC AIS
As a med mal claims manager, I feel that I will always have job security. The numbers of claims are down and I do not know why. Maybe some things are improving, but I do not really think so.
Unfortunately, a full hospital is a barometer of successful healthcare instead of an empty hospital.
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