State regulators have fined Cedars-Sinai Medical Center $25,000 in connection with a series of safety lapses in which incorrect doses of the blood-thinner heparin were given to children, including the newborn twins of actor Dennis Quaid and his wife.
Cedars was one of 11 California hospitals assessed penalties because of license violations that caused, or were likely to cause, serious injury or death, said Kathleen Billingsley, deputy director of the state .
"The hospitals take this extremely seriously," said Billingsley, adding that all hospitals fined had taken corrective action.
The Quaids' babies, Thomas Boone and Zoe Grace, were twice given 1,000 times the intended dosage of heparin on Nov. 18 while being treated at Cedars-Sinai, one of the nation's most prestigious hospitals. They were then given the drug protamine sulfate to reverse the effects of heparin and restore normal blood-clotting function, and they appear to have recovered fully.
Another child being treated at the facility also was given the wrong dose of the medication, often used as a flush to prevent blood clots around intravenous catheter sites. Heparin is among the most frequently used -- and misused -- drugs in the nation, according to U.S. Pharmacopeia, which operates a program reporting medication errors and adverse drug reactions.
In their first interview after the incident, Quaid and his wife Kimberly told The Times in January that they had been assured by Cedars-Sinai staff that their children were "just fine" on the day of the overdoses. They said they only learned the next morning that the children, born prematurely at 36 weeks to a surrogate, had twice been given heparin in a concentration of 10,000 units per milliliter instead of the appropriate 10 units per milliliter.
The error was discovered after nurses noticed Zoe oozing blood from an intravenous site on her arm and a spot on her heel, state records show.
"Our kids could have been dying, and we wouldn't have been able to come down to the hospital to say goodbye," Dennis Quaid said in the January interview.
The Quaids filed suit against a leading blood-thinner manufacturer in December, saying the labeling and design of the product led to a massive overdose of their newborn twins.
Between 2001 and 2006, more than 16,000 heparin errors were blamed on incorrect dosing, according to data U.S. Pharmacopeia prepared for The Times. Nearly 650 patients were harmed, including 12 who may have died, the group said. All told, at least 1.5 million Americans a year are injured after being given the wrong medication or the incorrect dose, according to the Institute of Medicine, part of the National Academies of Science.
Several other Southern California hospitals were also fined today for lapses in patient care. Among those fined were Scripps Memorial Hospital in La Jolla, Universal Health Services of Rancho Springs (Southwest Healthcare Systems) in Murrietta and Kern Medical Center in Bakersfield.
Kindred Hospital in Modesto received the highest penalty, fined by the state $75,000 for three separate violations, including failing to have procedures in place to monitor controlled substances.
andrew.blankstein@latimes.com
