Quaid Twins: Eye Openers to the Reality of Medical Errors

In late November 2007, the eyes of America were open to the reality of the threat of medical errors with the unfortunate experience of the Quaid twins. Dennis Quaid and his wife (pictured on the left) had put their two week old babies under the care of the staff of the Cedar Sinai Hospital, one of the most renowned hospitals in California. Little did they know that during the twins time at the hospital, they were going to be put under more danger than what they were admitted for. During one of the night shifts, the twins were administer a dosage of a blood thinner, Heparin, that was 1000 times what they needed. This put both twins into shock and they had to be transferred to the neonatal intensive care unit. There was another patient who also suffered the same problem, but their name was not disclosed. Fortunately, all three patients recovered from this medication error, and there are no signs of permanent damage. While the Quaid twins were able to survive this error, there have been other patients who have died from overdoses of Heparin. Though the Quaids are attributing this error to the pharmaceutical concepts, we must also considering the error in the delivery process administer by the hospital. It is the hospitals responsibility to ensure quality care to each patients, and thus should constantly be evaluating their performance so that errors such as these do not occur.

Even in a hospital as supreme in quality as Cedar Sinai Hospital, it is now evident that errors occur. In fact, according to the US Food and Drug Administration, 98,000 deaths a year can be accounted to medical errors. While the Quaid's are attributing this particular error to the pharmaceutical companies, it makes us wonder if there was anything the hospital could have done to prevent this error as well. Now a days, hospitals need to really begin to look at these problems internally and see what they can do to limit their liabilities without spending a surplus of money to prevent errors. For example, in the case of this overdose, perhaps if the person stocking the medicine realized that these two concentrations of the drug resembled each other, he or she could have made a sign to signal which vial was which, which would have probably been more cost efficient then they multiple days spent in the NICU and medicine to reverse the effects of Heparin.

If we look at the most frequent types of medication errors found within our hospitals, we can see that omission of a dosage is the most frequent. The bar graph on the right, provided by The Commonwealth Fund, a foundation which works to improve high performance in our health system, shows other causes as well. Improper dosage and prescription error are right below omission in frequency. All of these errors could potentially be solved, or at least reduced, by improving the systems performance of the hospital. Because more and more hospitals are realizing this concept, hospitals are moving towards a more factory based approach to reduce the number of mistakes within their practices.

One of the ways by which they are experimenting is by the use of the Six Sigma efforts, provided by General Electric. According to the Six Sigma Website, Six Sigma is a "measure of quality that strives near perfection". There are two processes by which this statistical measure can be achieved. One is called Six sigma DMAIC, which stands for define, measure, analyze, improve and control. The other one is Six Sigma DMADV which stands for define, measure, analyze, deign, and verify. Both of these methods try and achieve as little variation as possible.Through the use of these data based methodological process, companies can asses the efficiency and quality of their process, and install measure to constantly be improving and trying to achieve that Six Sigma, which would represent perfection. Many hospitals all across America are using programs such as this already. One of the hospitals that has seen results from the Six Sigma Efforts is St. Joseph Health Center in St.Louis. After implementing these processes, they were able to obtain a decrease in annual turnover as well as an increase in revenue and in emergency room admissions. By examining each part of their departments and really striving for the best, they have been able to radically turn around their hospital.

It is imperative that more hospitals look at constantly improving their system process to minimize the number of error that occur within their facilities. As hospitals, one of the main responsibilities and missions should be to save lives, not to endanger them. Errors such as the overdose of the Quaid twins are preventable and should be foreseen and accounted for. Only then will hospitals truly decrease their liabilities and become the health sanctuaries that we desire them to be.