TWINS BOUT WITH HEPARIN ERROR WAS A
NEAR-MISS OF INFANT DEATH
It was widely reported last November that the infant twins of actor Dennis Quaid and his wife Kimberly were erroneously injected with a massive dose of the blood thinner Heparin. Now, the full details of this catastrophe and how dangerously close to death the children came have been revealed by the family while appearing before a US House of Representatives hearing.
The twins, Thomas Boone and Zoë Grace, were only 11 days old when they developed a staph infection that placed them on a continuous intravenous drip of antibiotics at Cedars-Sinai Medical Center in Los Angeles. All treatment was proceeding smoothly until the point when the IV needed to be changed. Standard procedure at this point includes cleaning the IV line with 10 units of the blood thinner Hep-Lock to keep the medication flowing freely. In error, the twins each received a massive overdoses of 10,000 units of Heparin, which is 1,000 times the normal dose for babies.
The effect of the drug on these young bodies was to begin turning their blood to a water-like consistency. This is why after a short time, one of the children was seen to be bleeding through a foot puncture where blood had been drawn earlier.
Still, this did not raise an alarm. The IV drip continued. The next time the IV was changed, a second massive dose of Heparin was administered. It was not long after this that serious troubles for the twins really began, along with a totally frightful day for the parents.
When the error was discovered, the drug Protamin was injected in the children to counteract the Heparin, but did not take effect immediately. During the next few hours, the babies bled from many of the places they had skin punctures.
At one point, Quaid said that a doctor was working to put a clamp on a bleeding umbilical cord of his son when blood suddenly shot out at a height of some 6 feet and splattered against a hospital wall. All the while the children were screaming in pain, the parents were afraid for their children’s lives and were dreading long-term damage. Fortunately, both children did survive, are doing well and the possibility for long-term problems seems negligible.
What is so unfortunate about this entire ordeal is that it did not need to happen. About 1 year before, a similar mixup had occurred in an Indianapolis hospital where three children had died and three were injured. Drug maker Baxter Healthcare Corporation was involved there as well. The apparent mix-up in Indiana was very similar to the one Quaid described. The package labeling of Hep-Lock and Heparin were so similar in color and description that it was easy for hospital staff to confuse the two.
At that time, Baxter did send out warnings to hospitals about the possible problem but did nothing else for about 7 months when it finally requested a label change with the U.S. Food and Drug Administration. About the time of the Quaid incident the label changing was beginning to happen. However, Baxter never did anything by way of a product recall to get this potentially dangerous situation handled. Knowing the risks, it simply allowed the product to be sold, distributed and used with only the warning letter sent to alert hospitals to the potential problem.
The Quaids have filed a legal suit against Baxter. The company has filed to dismiss the suit claiming preemption.
Their argument is that since the FDA gave approval to Heparin and allowed it onto the market, the government has provided the “seal of approval” to sell it. Quaid described this approval as a drug company’s “get out of jail free card” and denies a citizen’s right to sue. The company chooses to operate in this fashion even though they know that an estimated 7,000 Americans die each year as a result of medication error and blood thinners are one of the main culprits.
ource: The U.S. House of Representatives. “Testimony of Dennis and Kimberly Quaid Before the Committee on
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