By Monte M. Korn
The facts for this column were taken from an article by Meg Grant titled “Dennis Quaid Wants to Save Your Life” in the September/October edition of AARP Magazine.
After Dennis Quaid’s Infant twins nearly died from an accidental drug overdose, the energetic actor found a bold new mission: to help hospitals prevent mistakes.
On the morning of November 19, 2007, the actor and his wife, Kimberly, rushed to Los Angeles’s Cedars-Sinai hospital—one of the nation’s best health care facilities—where their 12-day-old twins had been admitted two days before for treatment of routine staph infections. Their pediatrician and the head nurse met them at the door of their babies’ room, where a cluster of doctors hovered over Thomas Boone ( known as T. Boone) and his sister, Zoe Grace (or Z.G.). “We could see them working on the kids,” Quaid says. “It was chilling.”
The pediatrician quietly informed the nervous parents that the twins had inadvertently been massively overdosed with a blood thinner called heparin, putting them at risk of bleeding to death. “Initially, I felt this really couldn’t be happening,” the actor remembers. “Then I felt fear—and helplessness.”
Dennis and Kimberly went to the twins’ bedsides and watched, immobilized. “They were bleeding out of every place where they’d been poked and prodded,” says Quaid.
In an attempt to stanch the fl ow, a doctor placed a clamp on T. Boone’s umbilical cord. A stream of blood shot across the room, splattering the wall. “We were in shock,” says Quaid.
To reverse the effects of the heparin overdose—the infants had twice received 1,000 times the correct dose—doctors gave T. Boone and Z.G. a drug called protamine. Dennis and Kimberly refused to leave their bedsides for the next 32 hours , gently touching and trying to soothe their babies.
“They were really in a lot of discomfort, crying,” Quaid says. “It had to be painful.” Finally, late on the second day, the infants’ blood coagulation levels inched into the normal range. A neurologist and other specialists assessed brain and motor functions, which, miraculously, appeared normal.
Though Quaid wanted the crisis kept quiet, news leaked fast. “That may have been a blessing in disguise,” he says, “because a lot of people told us later they were praying for our babies. In the end, I believe that the power of prayer from so many is what saved them. It’s obvious to me that a higher power in the universe is controlling what’s going on.”
Whether by act of God or human error, Dennis Quaid was now a very different man, with a very different mission. After the twins were born, Quaid committed to spending more time just being a dad. “Being a parent is one of my favorite things in life,” he says. “It’s one of the most challenging experiences, and one of the most rewarding.”
Later, when the couple looked into the frequency of medical errors, they learned that U.S. hospitals are not required to publicly report errors, and that caregivers often conceal mistakes to avoid malpractice lawsuits. But a landmark 1999 report by the Institute of Medicine showed that 100,000 deaths occur in the United States each year as a result of health care harm. That report, coupled with a 2007 Centers for Disease Control report that an additional 99,000 people die annually from hospital-acquired infections, led the Quaids to deduce that health care harm is in fact the third-leading cause of death in the United States. As a jet pilot, Quaid uses an aviation analogy to drive home the numbers. “That’s the equivalent of 20 jet airliners full of passengers going down every week,” he says.
A handful of victims have spoken out about the problem—among them Sue Sheridan of Boise, Idaho. Her son, Cal, now 15, was insuffi ciently treated for jaundice as an infant and now suffers from a constellation of symptoms—cerebral palsy and auditory and vision impairment—known as kernicterus. Four years after Cal failed to be properly treated, Sheridan’s husband, Patrick, was diagnosed with a benign brain tumor; a follow-up pathology report indicating that the tumor was malignant was misfi led, and Patrick, late to begin treatment, lost his battle with cancer in 2002.
Today Sheridan heads up two nonprofi t organizations to address medical errors. One of them, Parents of Infants and Children with Kernicterus (PICK), has succeeded in requiring hospitals to test babies for jaundice before release.
Another is working to require health care providers to notify patients directly of their pathology results. When she read about what had happened to the Quaid twins, Sheridan says, “I had this sense of hope that somebody of Dennis’ stature and celebrity, who’d witnessed the fear and horror that I had, would speak up. And he did.”
After launching an investigation into how the overdose occurred, Quaid learned that nurses had twice mistakenly given each infant a 10,000-unit dose of heparin, used to treat illnesses in adults, instead of a similarly packaged 10-unit dose called Hep-Lock, appropriate for use in IVs for infants.
Three infants at Methodist Hospital in Indianapolis had died a year earlier from the exact same overdose. Soon after, Baxter Healthcare Corporation, manufacturer of heparin, changed how it packaged the two dosages. Instead of being identical in size and similar in color— one light and the other dark blue—the higher dosag e would now carry an orange label and a warning. But the company failed to recall the existing bottles. “Companies recall dog food!” exclaims Quaid. “Why weren’t they recalled?” The heparin given to the Quaid twins bore the old packaging.
The Quaids have sued Baxter for negligence; the case is currently pending. The couple settled with Cedars-Sinai when, according to Quaid, the hospital agreed to make changes to prevent such an overdose from occurring again. “We didn’t want to sue the hospital because we need really good hospitals,” Quaid explains.
“And as part of the settlement, Cedars spent millions—on electronic record keeping, bedside bar coding, computerized physician-order entry systems—to improve patient safety. I have to commend them for that.” (A spokesperson for Cedars-Sinai says the hospital began implementing such safety measures before the twins’ accident. “Immediately following this incident,” adds spokesperson Simi Singer, “we began additional focused education on medication safety and have implemented additional procedures and protocols for our pharmacy and nursing staff.”)
“In early 2008 Dennis and Kimberly established the Quaid Foundation, which called for hospitals to adopt bedside bar coding, requiring scans on patient’s wristbands to match scans on medications. “It’s based on the same technology that you have at every gas station and grocery store in America,”Quaid says. “If it’s the wrong medicine or the wrong patient, an alarm goes off.” Shortly after, Quaid met Charles Denham, M.D., a leader in the patientsafety movement and founder and chair of the nonprofi t Texas Medical Institute of Technology (TMIT), which tests systems to improve health care safety....
The Quaids folded their foundation into TMIT this year. “There are thousands of people who have been victims, whose voices have never been heard,” says Quaid. “We’re now coming together and demanding that something happen.”
“To that end, Quaid is narrating a series of documentaries produced by Denham about medical harm, which TMIT is distributing free of charge to every hospital in the country.
The fi rst in the series, “Chasing Zero: Winning the War on Healthcare Harm” (available for free download from TMIT’s website, safetyleaders.org), tells the stories of medical-error victims (including Sue Sheridan), as well as providers who have made mistakes.
“We’re not here to denigrate health care workers,” says Quaid. “They’ve dedicated their lives to treating human suffering—and they’re overworked.”
To download the entire article, visit www.safetyleaders.org/downloads/AARP_July2010_Quaid.pdf.
Monte M. Korn is an attorney practicing law in West Bloomfield, has been a member of the State Bar of Michigan since 1942, and is a member of the Probate and Elder Law Sections of the State Bar.
Monte Korn is the talk show host of “Open Line with Monte Korn” on radio station WNZK am690 every morning at 11 a.m. He can be reached at (248) 933-4334.
The material in the above article is the research of Monte M. Korn. The Detroit, Oakland County, and Macomb County Legal Newspapers have no responsibility therein.