A Los Angeles hospital put three children, including actor Dennis Quaid’s newborn twins, in danger by giving them overdoses of a blood thinner, California regulators said today.
The California Department of Public Health said the Cedars-Sinai Medical Centre gave the paediatric patients 1,000 times the intended dosage of heparin on November 18.
State regulators said the “violations caused, or were likely to cause, serious injury or death to the patients who received the wrong medication”, and they faulted the hospital for its “deficient practices” around administering the drug.
The 20-page report does not identify the patients, but the Quaid family’s representatives previously confirmed the babies’ involvement.
All three children recovered, but two needed a drug that reversed the effects of heparin.
The regulators’ report found that the hospital did not adequately educate staff about safe use of heparin, which it described as a “high-alert, high-risk” blood thinner, and that nurses sometimes failed to adequately read labels on vials of the drug.
Cedars-Sinai’s chief medical officer, Michael Langberg, said in a statement that the state’s review echoed the hospital’s own findings about the error and that the facility had cooperated fully with the investigation.
“While this is a rare event, we are pleased that the (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 apologised to the patients’ families and said it had made changes to prevent a recurrence, including providing more training and requiring four pharmacy workers to verify a high-alert medication before putting it in a patient care unit.
The Quaid twins were at Cedars-Sinai being treated for an infection. They were receiving intravenous medications and the heparin was used to flush the catheters to prevent clotting.
Quaid and his wife, Kimberly, have sued Baxter Healthcare, the Illinois-based maker of heparin, accusing the firm of negligence in packaging different doses of the product in similar vials with blue backgrounds.
A similar dosage error killed three premature babies at an Indianapolis hospital in 2006. Three others survived overdoses.
In February, Baxter Healthcare sent a letter warning health care workers to carefully read labels on the heparin packages to avoid a mix-up.