It Takes a Celebrity

Actor Dennis Quaid is suing Baxter Healthcare Corp after Cedars-Sanai Medical Center in California inadvertently flushed the catheters of his twin infants with 10,000 units/mL heparin instead of the 10 units/mL concentration that they should have used. At least one of the twins was administered protamine to reverse the effects of heparin, a blood thinner.

The hospital has said the error was preventable. The two strengths come in vials that are similarly sized, shaped, and colored. Mr. Quaid isn’t suing for a huge amount of money (only $50,000) - he simply wants the company to recall the product and make sure that the vials are distinguishable from each other. He doesn’t want this to happen again. According to the article, this med error also happened recently in Indiana, killing three infants.

Look-alike, sound-alike drugs are and have always been a problem (see Jim Plagakis’s blog about when he asked a nurse to clarify whether the doctor wanted hydralazine or hydroxyzine and she just said “yes”). I know in retail pharmacy it’s easy to grab the wrong bottle - especially when the manufacturer makes all their products look the same (I’m looking at you, Merck. Who can tell the difference between a bottle of Hyzaar, Cozaar, Zocor, Proscar, or Singulair without scrutinizing it?). Thankfully we have a scan-verify system where the label is scanned and then the correct drug product. If it’s the wrong drug, the system alerts us to the mispick. Unfortunately, it’s a “voluntary” scan-verify system. Prescriptions can still be sold if they were not scan-verified.

I make an effort to scan each and every prescription I dispense. I do not think that I am invincible. And as careful and competent as I am, I know I can still make a mistake. I take every advantage that I can.

I wonder if the hospital had the same sort of system for the nurses to use? Scan a barcode on the patient’s wrist or bed, then the drug vial - if that system was in place, this error would not have been as likely to occur.

I’m actually surprised that more drug administration errors aren’t reported by the media. Most nurses are highly competent and diligent about administering the right drug to the right patient. However, mistakes happen. It is up to the drug companies, hospitals, and individuals working with medications to make sure that error risk is minimized.

I think Mr. Quaid has the right idea about suing Baxter. I guess we, as healthcare professionals, have to be thankful that a celebrity is focused on this issue: it brings a lot of media attention and awareness to the problem. Such different strengths of heparin SHOULDN’T be kept in vials that look almost exactly the same. And unless the healthcare system is doing nothing to prevent errors, we are just waiting for them to happen.