by Natalie Finn
Wed, 9 Jan 2008 06:40:49 PM PST
The hospital at the center of the Quaid twin medical mixup has just gotten its wrist slapped.
The California Department of Public Health has issued a 20-page deficiency report detailing the various violations that resulted in Dennis Quaid's newborn twins and one other patient receiving an accidental overdose of anticlotting medication at Cedars-Sinai Medical Center in November.
Daughter Zoe Grace and son Thomas Boone ended up in the hospital's neonatal intensive care unit Nov. 18 after nurses mistakenly administered a 10,000 unit/milliliter solution of the blood thinner heparin, often used to flush out IV lines, rather than the 10 unit/milliliter dosage prescribed for infants.
Wed, 9 Jan 2008 06:40:49 PM PST
The hospital at the center of the Quaid twin medical mixup has just gotten its wrist slapped.
The California Department of Public Health has issued a 20-page deficiency report detailing the various violations that resulted in Dennis Quaid's newborn twins and one other patient receiving an accidental overdose of anticlotting medication at Cedars-Sinai Medical Center in November.
Daughter Zoe Grace and son Thomas Boone ended up in the hospital's neonatal intensive care unit Nov. 18 after nurses mistakenly administered a 10,000 unit/milliliter solution of the blood thinner heparin, often used to flush out IV lines, rather than the 10 unit/milliliter dosage prescribed for infants.
After a doctor noticed that the twins were oozing blood around their IVs, they were diagnosed and treated with protamine, which reverses the effects of heparin, per the report obtained by E! Online.
The Quaid babies, now two months old, appear to have made a complete recovery. "Everything looks good," the family's attorney said when the twins were released from the hospital Dec. 4. (The third baby didn't need the antidote and was discharged the night after receiving the overdose.)
"This violation involved multiple failures by the facility to adhere to established policies & procedures for safe medication use," the report reads, going on to cite a number of rules not followed, including a failure to "re-emphasize the facility-identified high-alert, high-risk medication heparin with pharmacy warning labels, segregation and double-checking."
A lawsuit filed last month by the Quaids against heparin maker Baxter Healthcare Corp. charges that the manufacturer has created a dangerous situation by using nearly identical labels to identify the 10-unit and 10,000-unit solutions.
A statement released by Cedars-Sinai at the time admitted that "preventable errors made by pharmacy and nursing staff," who failed to double-check the labels, "caused the wrong concentration of heparin to be used."
"These violations caused, or were likely to cause, serious injury or death to the patients who received the wrong medication," the CDPH's report concluded. "The facility [sic] systemic practices involving these failures to follow facility policies & protocols also had a potential to affect all patients in the hospital."
An internal investigation at Cedars-Sinai resulted in similar findings, according to a statement from chief medical officer Dr. Michael L. Langberg, and steps have already been taken to retrain staff, segregate the high-concentration heparin and review all policies and practices involving high-risk meds.
"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," Langberg said.
The hospital has been fully cooperative in the agency's investigation, Kathleen Billingsley, deputy director of the Center for Healthcare Quality, told the Los Angeles Times Wednesday.
Cedars-Sinai has 10 days to respond to the deficiency report, to ensure that patients are no longer "in immediate jeopardy," before the CDPH decides on a course of action.
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