Babies given wrong dose of Heparin @ Cedar Sinai

Interesting that the Quaid story on 60 Minutes would be followed by a piece about sleep deprivation, and how must it affects our minds and bodies on many levels, after just one night of 4 hours only of sleep. I've been saying for a long time that 12 hour shifts are not safe, and now this study would seem to bolster that. Wonder if the people at Cedars Sinai work 12 or 16 hour shifts?

I think you may be giving the position of nurses too much credit. I wish we were that esteemed. I can guarantee you if he sued the nurse and won, that wouldn't affect his box office one whit especially since he would have been well within his rights.

I'm not going to hold my breath for Dennis Quaid to come to the rescue of healthcare and medical error prevention. Errors happen everywhere, every day - the only difference is that they happen to us "common folk".

RN1989: Yes, this is a huge problem. There will always been human error, but understaffing is but one thing that fuels it. I keep accidentally writing "overstaffing" - maybe I'm thinking "overload" above all else. In recent history, I have noticed that these kind of things are also happening to the "noncommon" among us. Why is this? Some talk show host - Glenn Beck - had to wait a very long time in the ER, and made a public stink about it. Even if some illuminary is doing it for the publicity, it still brings important issues to light. In the past couple of months, both an elderly neighbor and a friend's father had med error type situations happen to them and I live in a very sparsely populated place.I don't have to tell you of all people how endemic this is - 200,000 die a year from med errors - awful.

RN: The only reason that anyone cares about what happened to him is because he used to be considered a hot Hollywood star. He's gone through women like kleenex over the past 25 years which makes me think he loses interest easily. I am not going to be impressed until I see that he follows through with effecting positive change and doesn't lose interest in the cause after a few years have gone by or his Hollywood popularity is gone. It always sounds great to say you are going to open a foundation for this and that but lots of people say it and nothing ever happens.

self disclaimer: I was a student nurse in '89. had to give it up. And now will graduate in 30 days (woot)

Ok so ....back the first time I went to nursing school....there used to be a med nurse. I wonder why they don't go back to that. Someone whose sole job for that shift was giving meds.

Do you all know why that changed and if you think it would be good to do again?

This will be featured tonight on "60 Minutes." The details have been posted in lengthy threads on this forum. I'm not aware of the moderators editing or deleting any of those posts.

As I recall, staffing was not the issue when the Quaid children were overdosed. The hospital still had heparin on its shelves that bore old labels. A nurse did not check the label and overdosed the children.

The Quaids are going after the drug company because they have no cause of action against the hospital or the nurse. That's because the children were given the antidote and recovered. Had they been damaged, the family would have a claim. I don't doubt that their lawyer gave another reason when speaking to a reporter about not going after the nurse, though. To say "we don't have a claim" diminishes the public view of their case.

It seems like if a nurse gave the wrong dose, there is a cause of action against that nurse, doesn't it? Not that it would have been solely the nurse's error, as the bottle should have been totally distinctively labeled and the pharmacy director should have been part of that labeling effort and Nursing directors should have had a hand in getting it properly labeled. But the nurse who actually made the error, unfortunately, is also liable. Right?

Are the twins alright?

Dahni,

A few points in your post jump out at me. First of all, simply because the babies did not suffer permanent injury that we know of, (They are infants, with many years of growth and development ahead of them during which deficits may become apparent.) does not mean that there are no damages. They spent more time in NICU than was otherwise necessary, were separated from their parents, were exposed to painful treatment, and their parents undoubtedly experienced extreme mental anguish over the possibility of losing their previously relatively healthy infants.


Jolie: You're right - who knows what the long term will bring? As well, you never know the source of the problem - some people are convinced that vaccinations cause autism in their kids - they may or may not be right, but either way, it can be so hard to prove.

J:Secondly, unless it can be demonstrated that the nurse acted recklessly or intentionally, s/he may not (and probably should not) lose her license over this incident.

D: Good to know - I was taken aback when I saw on a nursing license list that many people lost licenses for "charting errors" -could this be? Yes, it's a huge responsibility, but to err is human, as well.


The problem of mis-identifying heparin strengths is an issue that was well-known to the manufacturer, (who refused to address it following a similar incident in Indianapolis in which 3 babies died) and should have been well-known to any hospital with a NICU. Administration of a drug ultimately rests with the nurse caring for the baby, a huge responsibility. But not every error in medication administration is solely the fault of the nurse. There are systems errors that allowed the manufacturer to continue to supply medication in packaging that was likely to be confused, technicians (who are not pharmacists) who stock medication and are more likely to make a mistake in stocking than a pharmacist, unit-based policies and procedures that do not require cross-checking of medications like heparin flush, which are regarded to be "routine" meds, and staffing issues that may put time pressure on nurses caring for too many babies.

To insist that only the nurse administering the medication be disciplined is short-sighted and ineffective.

As for medication nurses - they are sometimes utilized in team-nursing settings, a care-delivery system that is not at all appropriate for a NICU, or any intensive-care setting.