The double-barreled news of Dennis Quaids’ twins receiving heparin doses 1,000x the prescribed dose while receiving medical treatment at Cedars-Sinai Medical Center, coupled with the tragic death of Kanye West’s mother following cosmetic surgery, focuses this health care paparazzi’s lens squarely on the role of information technology in health care.
The Cedars-Sinai Chief Medical Officer has termed the Quaid event a “preventable error.” Donda West’s doctor has been described by the likes of People magazine and the Los Angeles Times as a clinician with at least 2 DUI’s and an assortment of malpractice suits — as well as a recommendation by the Medical Board of California to revoke his license.
In both instances, information and sensible procedures might have avoided these sad scenarios.
At Cedars-Sinai, the Quaid twins and a third patient had intravenous catheters flushed with a concentration of heparin 1,000 times greater than the normal protocol. Nursing staff used vials of heparin with a concentration of 10,000 units per ml instead of vials with a concentration of 10 units per ml. See the bottles of heparin here, labelled with varying concentrations of heparin per ml.
The Institute for Safe Medication Practices, the nonprofit organization devoted entirely to medication error prevention and safe medication, counts anti-coagulants like heparin among “high-alert medications.” As such, heparin has a greater risk of causing significant patient harm when it is incorrectly used. ISP says, “Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients.”
That’s a medication error. What about surgical mistakes? Donda West was 58 years old. She was an accomplished academic who had chaired the English department at Chicago State University before she became involved with her son’s career. Dr. West’s autopsy confirmed that she died from complications from cosmetic surgery (including a tummy tuck, breast reduction and liposuction). According to several published sources, Dr. West had shopped around for cosmetic surgeons, some of whom warned her about pre-existing conditions that could put her at risk. Dr. West finally found a surgeon who would perform the procedure she wanted. A sort of celebrity-surgeon, his website calls him, “an on-air expert for CNN, MSNBC, and other network news shows.”
The editors of the News-Leader of Springfield, MO, put the chasm between health information and other types of consumer information succinctly, starkly: “If Dr. Donda West had been looking for a good turkey sandwich instead of a good plastic surgeon, she could have counted on the government to warn her away from the likes of the doctor whose actions seem to have cost her life. Downstairs from the Brentwood Surgery Center is a Quiznos sandwich shop, which bears a rating on its door attesting to its most recent grade from local health authorities. They inspect regularly, grade strictly and force businesses to warn the public when problems have been found inside. But that’s for turkey sandwiches or cups of coffee. Not for people who are cutting you open.”
Health Populi’s Hot Points: Rest-in-peace, Dr. West. Best luck and long life to the Quaid twins. We must learn from these events. Providers must be vigilant at correct dosing. Consumers must get real about their own health risks, and look into providers’ records. The medical establishment must get serious about monitoring and punishing physicians who provide sub-standard care. Providing access, and incorporating the right information at the right time — for providers and consumers — must be our goal.
This Thanksgiving holiday, I am grateful for my family’s and my health. I wish you all a healthy, joy-filled Thanksgiving.