The Quaid Infants: Blame the Processes

Last night, the CBS program “60 Minutes” did a nice job discussing process failures that led to the near-death last November of the newborn twins of actor Dennis Quaid and his wife Kimberly.

While the Quaid story is not new, many of the early news reports last fall focused on the fact that nurses gave the babies the wrong drug. However, the
”60 Minutes” report, presented by Steve Kroft, made it clear that this was not simply a case of human error, but the result of problems in the processes.

Much of the report focused on Baxter Healthcare, which makes the blood-thinner Heparin. The babies were supposed to receive a pediatric version of the drug, called Hep-Lock, but instead received the adult medicine Heparin – which is 1,000 times stronger. And they received it twice.

The babies survived, and apparently with no long-term damage, but only because doctors and nurses struggled for several days after the errors were discovered to fight the massive bleeding that was starting to occur.

The two different medicines were distributed in vials of identical size with near-identical, hard-to-read labels. Baxter has since redesigned one of the labels, but initially did not recall the old vials.

“60 Minutes” also pointed out that there are other medications where similar packaging causes confusion. In regard to Heparin, the report included a comment from Diane Cousins, vice president of U.S. Pharmacopeia, a non-profit public health group that maintains one of the largest databases on medication errors.

"What we see with Heparin is that it is almost always in the list of top ten drugs that are reported for medication errors, and almost always in the top ten that are harmful."

And in fact, there have been similar incidents elsewhere in the country where infants died.

Has anyone here ever heard of visual controls?

(One of our recently published books, The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods by Naida Grunden, includes case studies of medication errors.)

It can be argued that the hospital in this case, Cedars-Sinai in Los Angeles, bears some responsible as well for processes that lack the kind of mistake-proofing that might have prevented the error. The hospital has admitted that the mistakes were avoidable.

The Quaids are suing Baxter, but not the hospital.

"You haven't sued the hospital even though they're - all sorts of reports have been done and the hospital has acknowledged serious mistakes," Kroft asks Dennis Quaid.

"I'd like to see Cedar Sinai take the lead in doing something to change what's going on in what I consider to, in the end, a broken healthcare system in patient medical care," the actor says.

Quaid calls it a conspiracy of silence, where doctors protect nurses, nurses protect hospitals, insurance companies protect drug manufacturers. Almost no one, he says, is aggressively trying to find ways to eliminate medical mistakes. So the Quaids are in the final stages of launching a foundation they hope will help remedy a situation that almost destroyed their lives.

At least some hospitals are moving beyond that conspiracy of silence to improve their processes. Let’s hope more do so.

1 comment:

Ian Furst said...

I think most health care providers would quietly admit that it's more common than we want to admit and med errors are currently a fact of life (but hopefully improving with better systems). Anaesthesia is a great example -- one of the major causes of problems is the wrong drug and the reason is an anaesthetist will have 5-10 syringes (minimum) all laid out. I know some that use different size syringes for the visual cues but they're also supposed to be labelled (although that doesn't help in a stressful situation). The is no better arugment for 5S than situations like this. Add to that good visual cues, automatic drug delivery and other process improvements and you might have a chnace at beating the problem.