The Quaid Syndrome - Tort deform at it's worst!
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We are all just one accident away from being a victim of tort deform.
How do thirteen patients accidentally get a multiple doses of a drug as is prescribed? How do twin infants get 1000 times the required dosage? That is exactly what happened at Cedars Medical Center in Los Angeles to the Quaid twins.
Sources tell us the twins -- Thomas Boone and Zoe Grace -- were accidentally given a massive dose of Heparin, an anti-coagulant. Babies typically get 10 units. Our sources say they were each mistakenly given 10,000 units. The drug is used to flush out IV lines and prevent blood clots. We're told one dose was given on Sunday morning, another on Sunday evening.We're told as many as thirteen patients at Cedars were mistakenly given the overdose of Heparin, but the effects are more critical because of the age and weight of the twins.
This isn't new to the medical profession. What went wrong? A simple mistake? How can such a mistake happen 13 times with 13 different patients? When they no longer fear you suing them professional discipline becomes lax. And then we are all just one accident away from being victims of the tort deformer.
The FDA and Baxter International Inc. (a pharmaceutical company) are warning health care providers about mix-ups of two heparin products. These mix-ups recently resulted in the death of three infants. The deaths occurred when a higher dose of Heparin Sodium Injection, at 10,000 units a milliliter, was inadvertently administered instead of a lower dose. Both products are in the same size vial and use different shades of blue as the prominent background color on their label. The similarity between the two bottles makes providers prone to medical malpractice in administering the drug.
In July 2007 the FDA warned about mix ups involving heparin and insulin.
The New Jersey Department of Health and ISMP recommend a number of strategies to reduce the risk of these kinds of mix-ups. Here are some of them:
• Do not keep insulin and heparin vials next to each other.
• To avoid using vials that look alike, consider using heparin bags of 100 units/mL. Heparin prefilled syringes could be used for admixtures. And consider providing insulin to patient care units in pen devices rather than vials.
• Require independent double-checks of IV insulin and IV heparin doses and infusions, and also an independent double-check through each step of preparing TPN solutions.
• Write verbal orders directly on order forms and then verify the accuracy by reading back the order.
• Finally, when a patient develops unexpected, unexplained hypoglycemia, consider the possibility that a medication error may have occurred and take the following steps: discontinue all current infusions and hang new solutions, treat the patient as necessary with dextrose, and check for unintended additives by sending the infusion bag(s) for analysis.
For more information on this subject, please refer to the section on Drugs, Medical Devices, and Implants.