Update: Quaid twins stable after accidental overdose

Update: Cedars-Sinai has apologized for the mistake, calling it a ‘preventable error’ and ‘a failure tofollow our standard policies and procedures. There is noexcuse for that to occur at Cedars-Sinai.’ In addition, 3 patients were affected, not up to 13 as previously reported.

Originally posted 4:30 pm: TMZ reports that newborn twins Thomas Boone and Zoe Grace Quaid, 12 days, were among as many as 13 patients at Cedars-Sinai Medical Center to receive overdoses of Heparin — an anti-coagulant used to flush out IV lines and prevent blood clots — twice on Sunday.

Thomas and Zoe, born November 8th, were apparently given 10,000 units of the drug, instead of the usual 10, when a technician stored the Heparin in the incorrect place, and then did not check the dosage before administering it. TMZ’s sources say the babies started to ‘bleed out’ on Sunday evening, and are now stable in the NICU, being treated with Protamine to reverse the effects of the Heparin.

According to TMZ, although other patients were given the wrong dosage as well, the effects on the twins are much more critical given their young age and weight.

Dennis, 53, and Kimberly‘s rep released a statement, saying,

Dennis and Kimberly appreciate everyone’s thoughts and prayers and hopethey can maintain their privacy during this difficult time.

Source: TMZ

Thanks to CBB readers Angela, Karina, Sheri, Sarah, Christina, Candace, Jana, Mary Beth, Sarah, Christina, Jennifer, Joanne, Melanie, Annie, Bre, Alexandra and Leslie.

Comments

This makes me sick to my stomach! When you are working with babies/children, you have to be SO careful! On a side note- I am confused a little bit. If the medicine was being given at the hospital, would that mean that they were still there after being born. And if that is the case, why is there a pic of Dennis holding the babies in their carriers? What am I missing?

Sarah’s note: I was confused by that myself. I *think* they probably were released unless there were additional problems, because they were fantastic weights for twins at birth — Thomas was 6 lbs 12 oz and Zoe was 5 lbs 9 oz — so I’m not sure how they ended up back in the hospital (assuming they did leave initially, as the picture makes it look like).

- angelbaby33 on November 20th, 2007

My goodness! So glad to hear they are doing okay… This picture makes it look as if the babies had been discharged from the hospital at some point. Did they start having the reactions after going home or were they back in the hospital for some reason? If they’d been taken home they are very, very lucky!

- Rachel on November 20th, 2007

That is horrible! I hope they continue to do well and get better! One thought on why they were back in the hospital is for jaundice, it’s pretty common in new babies, especially those a little early. My older daughter was 5lbs9oz and needed treatment for jaundice

- Amanda on November 20th, 2007

I hope these poor babies will be okay. I’m confused about why they were back in the hospital and being given the drug in the first place! My duo were born at 6lbs15oz and 5lbs12oz and went home with me when I was released. We did have a little jaundice but they didn’t go back into the hospital for treatment, we luckily were able to handle it at home w/their pediatrician.

- Sarah on November 20th, 2007

How the hell can that be possible?! That is horrible! I hope they are alright.

- Hea on November 20th, 2007

wow – that’s awful. we were there two weeks earlier – that could have been us…

- meghan on November 20th, 2007

Wow, that is horrible. I hope they and all the other babies affected by this are okay and have no long term (or short term) effects from this.

- Charity on November 20th, 2007

Apparently this has happened before to six babies and three of them died.

http://www.theindychannel.com/news/9891816/detail.html

You wonder why they didn’t change the labels back then, so they weren’t so similar. They should have learnt from that mistake, but now it happened again.

I hope the twins and the 11 other patients survive without any damages.

- Majbritt on November 20th, 2007

Majbritt-
I just read the article and it is so sad. Especially at the end when it goes on to say that the hospital is offering to pay for the funerals of the little babies that died and for counseling. Ummmmm, is that all they are offering??? I know it is not about money in a situation like that because the families just want their babies to be okay but the hospital should have to pay for its mistakes out of their nose!!

- angelbaby33 on November 20th, 2007

Well I’m sure they will be paying out of their noses eventually, but how is would it be appropriate for these hospitals to talk about negotiating damages while a family’s burying their baby? It’s not.

- terri on November 20th, 2007

People Magazine’s website is stating that the twins were recently hospitalized, and that Dennis’s rep declined to comment on why that was. From what I could tell from the article, the twins were given the overdose after being hospitalized. What surprises me the most (other than the overdose itself) was that BOTH twins needed to be hospitalized.

- Annoyomus on November 20th, 2007

OMG!!! Thank goodness they are doing okay!

- Poshie T on November 20th, 2007

Heparin is used to flush IV catheters to prevent obstruction. Because of the size of an infant, even the tiny amount used for the procedure could cause an effect. This is exactly the kind of potential error that keeps nurses awake at night. Procedures involving medications are very stringent. However, after long hours, often in the middle of the night, the brain, honestly, starts to slip. That is why completing every label check is critical, so that you prevent the “auto-pilot” that tends to kick in when you’ve done something a million times. On one hand, this is a wake-up call to all of us nurses to stay sharp with our safety measures. On the other hand, this sounds like a frighteningly easy mistake to make. My heart is with the nurses at this time, as well as family, because I’m sure they’re simply sick over this.

- Shmoo on November 21st, 2007

Does anyone know if there are any after effects from an error like this? In other words will the children affected have long term concerns?

- SY on November 21st, 2007

I agree that they should not be talking money in regards to the article but then they should have kept quiet all together. I just think that it seems a little off that they first thing they do is offer to pay for the funeral and counseling. Like they should be given a pat on the back for doing something good.

- angelbaby33 on November 21st, 2007

My prayers are with the family for a speedy recovery and a clean bill of health. I cannot imagine how badly I’m sure the nurses involved feel. I have ‘good’ memories of being sick when I was younger thanks to my nurses.

As a preemie, I was in and out of the hospital a few times so its not too shocking to me that they are back in. Jaundice, then bronchitis, then some sort of virus. Granted I was much tinier than these two, but still with very young babies its usually better to monitor them so that they have an easier recovery.

- Alexa on November 21st, 2007

Oh, my God, this horrible case reminds me of a recent case in my country. In one czech hospital a male nurse killed 8 people and tried to kill 7 by overdose of Heparin. The man has been arrested and the trial is being prepared. I think that Cedars Sinai should very carefully investigate if this isn’t done on purpose.

- Petra on November 21st, 2007

This is so horrible, and I imagine that there have to be some short- or long-term effects. The babies are so tiny, how could there not be? What I don’t understand, is how you mistake 10,000 units for 10? Even if the labels are identical, wouldn’t 10,000 units simply look like much more volume to administer? I’m not a health practitioner, so I haven’t got a clue.

- Avalulu on November 21st, 2007

I am a nurse in the NICU. I just wanted to give an FYI to the questions and curiosity. The packaging on the medication is changed quite often so that people do stay alert to the various doses. In the NICU that I work at we have changed the locations for all the doses so that in administration or an emergency the wrong dosage is not grabbed/given. We have several check points before the dose is even in the baby. The nurse is required to check all meds with another nurse and do the calculation again before administration. This follows the 5 rights of medication administration. Yes, mistakes are made, but with various check points in place this shouldn’t happen. This story does seem a bit fishy, and the only thing that I can surmise is the suremed where the med was placed was loaded incorrectly and then several nurses at the same time pulled the med. When the first dose/s were given incorrectly, other nurses were probably not aware of it or had already given the med.
We don’t live in a perfect world and yes, nurses/doctors/pharmacists/techs do make mistakes but that is all the more reason to go to nursing school and help decrease the nursing deficit.

- Erin on November 21st, 2007

To Avalulu, no, it would look the same. It would be the percentage of active ingredient. 10 u per ml, or 10,000 u per ml. The nurse administered a more potent dose, rather than a dose of greater volume (I assume). Heparin has a temporary effect, and protamine sulfate is an antidote. Any permanent injury would be caused by bleeding.

- Shmoo on November 21st, 2007

i feel for the nurses on this as well as the famillies. im sure they never meant for anything like this to happen and are probably feeling downright awful. i hope that measures are put in place so that this doesn’t happen again.

- sarah on November 22nd, 2007

In a few articles about this story, they have said a technician or an EMT administered the medication. I’m confused. Why would anyone but a nurse be giving the medication?

- kate on November 22nd, 2007

You don’t have to be a registered nurse to give medicine last I checked in CA; they have all kinds of technicians in hospitals that can do so.

- Lindy on November 27th, 2007

I can’t remember who asked about both babies needing to go back into hospital in the first place but I would say maybe it was a case of one of the twins showing problems then they would take both in just in case. As far as I know anyway.
Hope the wee angels are ok.

- dee on December 8th, 2007