Download Dennis Quaid Recounts Twins` Drug Ordeal

Dennis Quaid Recounts Twins' Drug Ordeal
Aug. 24, 2008
(CBS) This segment was originally broadcast on March 16, 2008. It was updated on Aug. 22, 2008.
Chances are you probably know someone who has died, or nearly died, because of medical mistakes in a hospital. It's much more
common than most people realize, and if it can happen to the children of movie star, at one of the finest hospitals in the country, it can
happen to anyone.
Dennis Quaid has starred in more than 50 films, but nothing prepared him for the drama and the near tragedy that unfolded last
November at Cedars-Sinai hospital in Los Angeles, when his infant twins were given massive overdoses of a blood thinner that nearly
killed them.
When 60 Minutes first broadcast this story in the spring, Quaid and his wife, Kimberly, had kept most of their thoughts and many of the
details private. They decided then to talk about what happened, what caused it, and what needs to be done to keep it from happening
to somebody else.
"It was the scariest, most frightening day that I think either of us have ever been through, to come face to face with your little kids who so young in that kinda situation," Quaid tells correspondent Steve Kroft.
And few couples had tried harder to have kids than Dennis and Kimberly Quaid. They had suffered through five miscarriages, before
finally turning to a surrogate to carry, what turned out to be twins, Thomas Boone and Zoe Grace, conceived with the Quaids' own
sperm and eggs.
Photos: Dennis Quaid
But within a few days of coming home, the twins showed signs of a having a staph infection and doctors recommended they be
admitted to Cedars-Sinai hospital for routine treatment with intravenous antibiotics.
On their second day there, the Quaids were told that the babies were doing fine, so they went home to get a few hours of rest, leaving
instructions to be called if there were any problems. But around 9 p.m. that night, Kimberly Quaid had a mother's premonition that
something had gone wrong.
"I just had this horrible feeling come over me and I felt like that the babies were passing. And I just had this feeling of dread," she
recalls.
"Kimberly even made a note at the time that she had the feeling, for some reason," Dennis Quaid adds. "And I called the room. And I
was put through to the nurse who was in our room with the kids. And I said, 'How are the kids?' And she said, 'They're fine. They're just
fine.'"
But Quaid says they weren't fine.
In fact, around the time of the call, the nurses had discovered that both twins were in serious danger. They were supposed to have
been given a pediatric blood thinner called Hep-lock to flush out their IV lines and prevent blood clots. But instead, they had been given
two doses of Heparin, the adult version of the drug, which is 1,000 times stronger.
"We all have this inherent thing that we trust doctors and nurses, that they know what they're doing. But this mistake occurred right
under our noses, that the nurse didn't bother to look at the dosage on the bottle," Dennis Quaid tells Kroft. "It was ten units that our kids
are supposed to get. They got 10,000. And what it did is, it basically turned their blood to the consistency of water, where they had a
complete inability to clot. And they were basically bleeding out at that point."
"There was blood oozing out of little blood draws on their feet, and things like that, you know, through band-aids," he adds.
Quaid says that's what first alerted the nurse that there was a problem.
But the hospital never called the Quaids and they didn't find out that anything was wrong until the next day when they showed up at the
hospital early the next morning and went to the twins' room.
"We were met at the door by our pediatrician, the nurse - head nurse that was on duty," Dennis Quaid recalls.
"Risk management," his wife adds.
"Risk management, which is basically the liability division of a hospital, which is lawyers," he explains.
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Inside the room, the Quaids found their babies bruised and bleeding from all the puncture wounds, where blood had been drawn or
where they had received injections.
"They were working on Boone, whose belly button would not stop bleeding. And while they were trying to clamp it, blood squirted
across the room, about six feet and landed on the wall. It was blood everywhere," Dennis Quaid says.
"They weren't just given one massive overdose, they were given two massive overdoses?" Kroft asks.
"Two massive overdoses, a thousand times what they should have over an eight-hour period that we know of," Quaid says.
Asked how serious the situation was, Quaid tells Kroft, "It was a life-and-death situation."
"And all of it because of mistakes?" Kroft asks.
"Yeah. It was avoidable, completely avoidable," he says.
And to make matters worse the same avoidable mistake had occurred a year earlier at Methodist Hospital in Indianapolis. Six infants
were given multiple adult doses of Heparin instead of the pediatric version; three of the infants survived, three did not.
Asked when he found out about the Indianapolis incident, Quaid says, "In the morning when I had gone in, a pediatrician told me about
it."
"He said, 'This has happened before'?" Kroft asks.
"Yeah. He had told me about that three babies died. And it sent a chill down my spine," Quaid remembers.
The Quaids say the crisis went on for 41 hours, as doctors and nurses administered an antidote to Heparin, which helps the blood
coagulate. Slowly the twins began to stabilize, and after 12 long days in the hospital, they were allowed to come home.
When 60 Minutes saw them last winter at the Quaids' house in Pacific Palisades, Thomas Boone and Zoe Grace were almost four
months old. Both have undergone extensive medical tests and they seem to have come through the ordeal with no signs of permanent
damage.
But the experiences changed Dennis Quaid. He's spent much of the past nine months trying to dissect what happened and figuring out
ways to draw attention to what is one of the leading causes of death in America - preventable human medical error.
"These mistakes that occurred to us are not unique. And they're not unique even to Cedars. They happen in every hospital, in every
state in this country. And 100,000 people, that I've come to find out, there's 100,000 people a year are killed every year in hospitals by
a medical mistakes," he says.
Because the deaths occur one at a time, all over the country over an extended time period, Quaid says the issue has slipped under the
public's radar. "It's bigger than AIDS. It's bigger than breast cancer. It's bigger than automobile accidents. And, yet, no one seems to be
really be aware of the problem," he says.
The causes range from misdiagnosis to surgical errors to medication mistakes like the accidental Heparin overdose that that nearly
killed the Quaid twins, an occurrence that’s not all that unusual, according to Diane Cousins. She's the 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," Cousins tells Kroft.
"What is it about Heparin that there's so many mistakes?" Kroft asks.
"Well, Heparin is very commonly used in the hospital. And the number of opportunities for error are very high," she explains.
But Cousins says another contributing factor with Heparin is labeling that can easily lead to mistakes. The 10-unit pediatric dose and
the 10,000-unit adult dose come in vials of identical size and shape and in different shades of blue that can easily be confused, if not
seen in reference to each other. And they are not the only drugs with that problem.
Asked to give some examples, Cousins, showing two medications, tells Kroft, "In this case, we have a solution of Lidocaine, which is
an anesthetic often used to swab a child's throat or mouth for mouth pain. Here, you have lithium oral solution used for manic
depression."
"Lithium is not something you'd wanna give a child. Absolutely not," she says.
The two small vials Cousins used as an example both have blue caps and cluttered labels, but one contains a hormone and the other a
children's antibiotic.
"If you're at arms' length, it's hard enough to read these labels because of their type size," Cousins says.
"And I'd need my reading glasses," Kroft remarks.
Baxter International, which manufactures the Heparin given to the Quaid twins, was fully aware that there had been fatal mistakes that
may have been caused by confusion over its labeling.
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When the three infants in Indianapolis died after receiving an adult dose, Baxter issued a nationwide safety alert, and last October
began shipping Heparin with a redesigned, peel-off label to end the confusion. What it didn't do was recall the old stock that was sitting
in hospitals all over the country, including Cedars-Sinai in Los Angeles.
"And as a result, our kids were given an old stock which was basically the same packaging and form that the kids in Indiana had
gotten. Now, they recall toasters. They recall trucks. They recall dog food that came from China last year. But they don't recall
medicine that kills people if you give it in the wrong dosage," Dennis Quaid tells Kroft.
The Quaids believe that Baxter was the first link in a series of events that led to the overdosing of their infants and they're suing the
company for negligence on behalf of their children.
Debra Bello, a senior director at Baxter, says there was nothing wrong with their product, and it wasn’t their fault. "One of the most
important components of medication administration is to read the label, and not rely on color, shape or size," she says.
"You sent out this warning which mentions not to rely on the color but to read the label…and you redesigned it," Kroft remarks. "When
you designed this new vial, why didn't you recall the old ones?"
"These vials are given over 100,000 times each day, safely, effectively. But nothing replaces reading that drug before you administer
it," Bello says.
Asked if the company didn't think it was necessary to recall those drugs, Bello says, "No, because the product was safe and effective
and the errors, as the hospital was acknowledged, were preventable and due to failures in their system."
That's not in dispute. A California Department of Health Services investigation found that there had been at least three critical systems
failures at Cedars-Sinai hospital, in which pharmacy technicians and nurses neglected to check the drugs they were distributing and
administering. Thomas Priselac, the president and CEO of Cedars-Sinai, didn't dispute the findings.
"This was a preventable error. It was the result of human error," Priselac says.
"You're talking about a situation here where you had three different people make a mistake," Kroft points out.
"Yes," Priselac acknowledges.
"What coulda been a fatal mistake. You got the people who put the wrong drug in the drawer. You got the people who picked it up and
brought it to the floor. And you got the nurses that looked at it - or didn't look at it - and put it in the IV line. Three people," Kroft says.
"Any time an error occurs, almost by definition, the unusual or the unexpected is what's occurred. And certainly in this particular case,
that's what occurred," Priselac says. "We have to make sure we have backup systems that pick up things when human error may occur
to prevent that error from manifesting itself."
"But you had backup systems. You had three people," Kroft remarks.
"Right," Priselac replies.
"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 have
launched a foundation they hope will help remedy a situation that almost destroyed their lives.
"You're lucky," Kroft remarks.
"Yeah. Extremely lucky. And not a day goes by since then that I don't think a day this ones changed for me, is that I don't take a day for
granted anymore 'cause if they hadn't made it, there never woulda been another happy day, really," he says.
A number of things have happened since 60 Minutes first aired this story: Dennis Quaid told his story to Congress, and Baxter
International withdrew all of its Heparin products from the market because of contamination issues.
But the problem of preventable medical errors and the problems with Heparin persist. Last month, 14 babies at a Corpus Christi
hospital were given an accidental overdose. Two of the infants eventually died.
Produced by Ira Rosen
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