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Prescription Error via Bad Packaging: The Quaid Twins

LOS ANGELES - Actor Dennis Quaid’s newborn twins were among three patients accidentally given 1,000 times the common dosage of a blood thinner, but hospital officials said none of the overdose victims had suffered any ill effects.

Cedars-Sinai Medical Center declined to identify the patients, but a representative for the actor told The Associated Press that they included the 2-week-old children of Quaid and wife Kimberly — Thomas Boone and Zoe Grace.

Mr. Quaid’s newborn children were fortunate that the medical staff at Cedars-Sinai were able to recognize the drastic error in the level of their medication. Had the twins continued to receive the drug unabated, the result could have been death.

The drug is called Heparin, which is an anti-coagulant and blood thinning medication. It was being used to flush out the catheters that the twins and another patient were using to receive intravenous medication.

The Quaids filed a lawsuit, but did not direct the suit at the medical staff that made the error. Instead, they filed the suit against Baxter Healthcare, who are the manufacturer of the drug that was mistakenly administered to the children.

You can bet that several cynical naysayers will assume that the lawsuit was filed against the drug manufacturer simply because there is more money there. But Dennis Quaid is a successful Hollywood actor, and a well paid one at that. He hardly needs a million dollar settlement to get by. It should also be mentioned that the lawsuit is for $50,000, which is normally about what a pharmaceutical company spends on taking doctors out to lunch in a week.

The central issue is how the drug is packaged. It should be remembered that this is a drug with properties that are designed to affect the chemistry of the blood. As quoted in the lawsuit that was filed:

“…both the 10 unit/ml vial of Hep-Loc and the 10,000 unit/ml of Heparin had a blue background to its label. This fact made them more difficult to distiguish if they had different background colors….”

In other words, both the minor dose and the major dose came in bottles that were the same color. But the similarities between the packaging of the two doses do not end there:

“…since a medical error in administration could lead to a dangerous or fatal result, the vials should have been in completely distinguishable size and shape.”

The Quaids are quite reasonably contending that if you have a drug that comes in remarkably different doses, it would be common sense to make it obvious that this is the case. A simple way to accomplish this would be to have different shaped vials, or at the very least, different colored labels. You can bet that companies that manufacture morphine differentiate between minor and major doses in their packaging.

It’s the same reason that cold remedies for toddlers usually comes with eyedroppers to administer the correct dosage, and it’s the same reason that it comes in brightly colored and easily recognizable packaging. Nobody wants to accidentally overdose their child on the wrong sort of NyQuil.

While this is an obvious solution for those that make all sorts of products for children and adults, for some reason it didn’t occur to Baxter Healthcare. And it wasn’t just Mr. Quaid’s newborn children that had to bear the brunt of this poor packaging decision. Three premature babies died in an Indianapolis hospital last year because of the exact same mix-up with the exact same drug. In response, Baxter Healthcare issued a safety alert to hospitals and healthcare providers. While that is all very well, they still failed to adequately address the problem.

Prescription errors are a real enough danger in hospitals without having radically different doses of a drug being packaged in practically identical containers. Patient histories can be misread, handwriting can be hard to read, and drugs that do completely different things to the body can have practically identical names. The FDA estimates that at least one person dies every day due to prescription error, and 1.3 million people suffer injuries. There are simple, common sense courses of action that pharmaceutical companies can take to at least trim the numbers a bit, and making their packaging obvious is one of them.

Baxter healthcare will no doubt be easily able to swallow a $50,000 judgment. And they should also easily be able to absorb the costs of repackaging their products. They should consider themselves lucky that Mr. Quaid’s children are recovering and doing well, and they should also consider themselves lucky to be given a relatively low cost opportunity to truly fix what is wrong with their product before someone else is injured.