Cedars-Sinai Medical Center's handling of high-risk drugs placed its pediatric patients in immediate jeopardy of harm, the state said Wednesday in its response to an overdose involving the newborn twins of actor Dennis Quaid.
In a 20-page report, the California Department of Public Health said the prestigious Los Angeles hospital gave the twins and another child 1,000 times the intended dosage of the blood thinner heparin Nov. 18.
"This violation involved multiple failures by the facility to adhere to established policies and procedures for safe medication use," state inspectors wrote. "These violations caused, or were likely to cause, serious injury or death to the patients who received the wrong medication."
In addition, the unsafe medication practices "created a risk of harm for all hospital patients," the report said.
The public health agency has not yet decided whether to fine Cedars-Sinai for the lapses, said Kathleen Billingsley, deputy director of the state's Center for Healthcare Quality. She said the hospital has fully cooperated in the investigation.
Cedars-Sinai has 10 days to respond to the deficiency report but already had taken steps to ensure that patients were no longer in "immediate jeopardy," Billingsley said.
An immediate jeopardy citation is relatively rare and indicates the severity of a hospital's mistake.
Addressing the incident for the first time publicly, Quaid and his wife, Kimberly, said in a statement to The Times that they felt "relieved" to know more about what happened to their children. They also criticized Cedars-Sinai for what they characterized as a lack of candor about what happened.
The Quaids said senior hospital officials told them that their children received only one overdose of heparin, but the state report cited two instances.
"We find it outrageous and totally unacceptable that we are learning for the first time, along with anyone else who reads the newspaper, exactly what transpired," the Quaids said.
In a written statement, Dr. Michael L. Langberg, Cedars-Sinai's chief medical officer, said the state report confirmed the hospital's internal findings, which identified at least three separate safety lapses that led to the overdoses.
"While this is a rare event, we are pleased that the [state 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.
