At 6 o'clock the next morning, after a fitful sleep, the couple returned to the hospital, where they learned of the overdose. As they rushed to be with the twins, they were intercepted by representatives from Cedars-Sinai's risk-management division. "That's a team of lawyers, because the hospital is concerned about liability and not as much about the health and welfare of our kids," a still outraged Quaid says today.
Later, when the couple looked into the frequency of medical errors, they learned that U.S. hospitals are not required to publicly report errors, and that caregivers often conceal mistakes to avoid malpractice lawsuits. But a landmark 1999 report by the Institute of Medicine showed that 100,000 deaths occur in the United States each year as a result of health care harm. That report, coupled with a 2007 Centers for Disease Control report that an additional 99,000 people die annually from hospital-acquired infections, led the Quaids to deduce that health care harm is in fact the third-leading cause of death in the United States. As a jet pilot, Quaid uses an aviation analogy to drive home the numbers. "That's the equivalent of 20 jet airliners full of passengers going down every week," he says.
A handful of victims have spoken out about the problem—among them Sue Sheridan of Boise, Idaho. Her son, Cal, now 15, was insufficiently treated for jaundice as an infant and now suffers from a constellation of symptoms—cerebral palsy and auditory and vision impairment—known as kernicterus. Four years after Cal failed to be properly treated, Sheridan's husband, Patrick, was diagnosed with a benign brain tumor; a follow-up pathology report indicating that the tumor was malignant was misfiled, and Patrick, late to begin treatment, lost his battle with cancer in 2002.
Today Sheridan heads up two nonprofit organizations to address medical errors. One of them, Parents of Infants and Children with Kernicterus (PICK), has succeeded in requiring hospitals to test babies for jaundice before release. Another is working to require health care providers to notify patients directly of their pathology results.
When she read about what had happened to the Quaid twins, Sheridan says, "I had this sense of hope that somebody of Dennis's stature and celebrity, who'd witnessed the fear and horror that I had, would speak up. And he did."
Once the twins were stabilized, their father looked at them, each in a tiny Isolette, and felt an overpowering sense of gratitude. "They were finally sleeping," Quaid says. At that moment he made a vow—to help ensure that what happened to his babies would never happen to anyone else. "I thought, 'They're 12 days old, and they're going to change the world.' "
After launching an investigation into how the overdose occurred, Quaid learned that nurses had twice mistakenly given each infant a 10,000-unit dose of heparin, used to treat illnesses in adults, instead of a similarly packaged 10-unit dose called Hep-Lock, appropriate for use in IVs for infants. Three infants at Methodist Hospital in Indianapolis had died a year earlier from the exact same overdose. Soon after, Baxter Healthcare Corporation, manufacturer of heparin, changed how it packaged the two dosages. Instead of being identical in size and similar in color—one light and the other dark blue—the higher dosage would now carry an orange label and a warning. But the company failed to recall the existing bottles. "Companies recall dog food!" exclaims Quaid. "Why weren't they recalled?" The heparin given to the Quaid twins bore the old packaging.
The Quaids have sued Baxter for negligence; the case is currently pending. The couple settled with Cedars-Sinai when, according to Quaid, the hospital agreed to make changes to prevent such an overdose from occurring again. "We didn't want to sue the hospital because we need really good hospitals," Quaid explains. "And as part of the settlement, Cedars spent millions—on electronic record keeping, bedside bar coding, computerized physician-order entry systems—to improve patient safety. I have to commend them for that." (A spokesperson for Cedars-Sinai says the hospital began implementing such safety measures before the twins' accident. "Immediately following this incident," adds spokesperson Simi Singer, "we began additional focused education on medication safety and have implemented additional procedures and protocols for our pharmacy and nursing staff.")