Dennis Quaid's Quest

On the afternoon of November 17, 2007, after the company had left, Dennis and Kimberly settled in with their brood. Then Kimberly, a hypervigilant new mom, noticed a sore on T. Boone's umbilical cord. Z.G. had a similar irritation on one of her fingers. The couple's pediatrician sent them to Cedars-Sinai, where both children tested positively for staph and were admitted for treatment with IV antibiotics.

Initially, Dennis and Kimberly would not leave the twins' bedsides. They even watched the next morning as a nurse dispensed a substance into their IVs. She explained that it was Hep-Lock, routinely used to prevent blood clots at IV sites. Without knowing it, the new parents had just witnessed the first of two overdoses of heparin (the next given several hours later when the IV bags needed changing ).

That evening, exhausted, the couple finally headed home. They were sitting in their living room, trying to unwind, when suddenly, at 9 p.m., Kimberly panicked, repeatedly saying, "They're passing. The kids are passing." Quaid thought she was reacting from fatigue, but he phoned the hospital and spoke to the on-duty nurse, who told him the twins were fine. Quaid believes the nurse probably knew about the overdose then but had been told not to notify them because they needed rest. "Our kids could have died that night," says Quaid, "and we wouldn't have been there for them."

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.")

In early 2008 Dennis and Kimberly established the Quaid Foundation, which called for hospitals to adopt bedside bar coding, requiring scans on patient's wristbands to match scans on medications. "It's based on the same technology that you have at every gas station and grocery store in America," Quaid says. "If it's the wrong medicine or the wrong patient, an alarm goes off." Shortly after, Quaid met Charles Denham, M.D., a leader in the patient-safety movement and founder and chair of the nonprofit Texas Medical Institute of Technology (TMIT), which tests systems to improve health care safety. The son of a NASA rocket scientist and a jet pilot himself, Denham bonded with Quaid over their mutual enthusiasm for aviation—they own the same-model jet (a Citation). "We were a perfect team," Denham says. "We both believe that this is what we're supposed to do and that we can save lives doing it."

The Quaids folded their foundation into TMIT this year. "There are thousands of people who have been victims, whose voices have never been heard," says Quaid. "We're now coming together and demanding that something happen." To that end, Quaid is narrating a series of documentaries produced by Denham about medical harm, which TMIT is distributing free of charge to every hospital in the country. The first in the series, "Chasing Zero: Winning the War on Healthcare Harm" (available for free download from TMIT's website, safetyleaders.org), tells the stories of medical-error victims (including Sue Sheridan), as well as providers who have made mistakes.

One of them is Julie Thao, a Madison, Wisconsin, single mother of four, who spent 20 years as a nurse specializing in obstetrics and perinatal bereavement and loss counseling. "This was where I found my true validation in life," says Thao. All that changed in early July 2006. After working an 18-and-a-half-hour double shift, resting briefly, then starting a new shift, she connected what she thought was an IV antibiotic to a 16-year-old pregnant patient whose labor was about to be induced. The IV bag she hung, which looked identical to the antibiotic bag, actually contained an epidural solution that is fatal if put in the bloodstream. Within moments, the patient's heart stopped. Doctors performed an emergency C-section and saved her baby boy, but they could not resuscitate the mother.

Thao, charged with manslaughter, ultimately settled for a misdemeanor, requiring her to serve a year of probation and restricting her from practicing nursing until February 2013. But worse than any court-mandated punishment is her agonizing guilt. For months after the incident, "all I wanted was death," Thao says. "For so many years I'd been the one who took into my arms the mothers whose children had been taken from them. Now I was the one who took a child from its mother."

Thao got back on her feet, in part after Denham offered her a position at TMIT. She now speaks at health care safety conferences, sharing her story and emphasizing that health care providers are human and will, under a variety of circumstances, make mistakes.

"We're not here to denigrate health care workers," says Quaid. "They've dedicated their lives to treating human suffering—and they're overworked."

"We are treating sicker and sicker patients, faster and faster, with more complex treatments requiring more specialization, which fragments the care even more," says Denham. "And we're cutting corners due to cost containment. We don't have bad people. We have bad systems."

Quaid and Denham are now calling on hospitals to invest in a set of 34 practices (called the National Quality Forum Safe Practices for Better Healthcare)—everything from simple checklists to computerized infection control. "Our community-hospital boardrooms decide where the money is spent and whether it goes to patient safety," says Denham. Quaid and Denham also believe an oversight agency similar to the National Transportation Safety Board (NTSB) should be established to monitor and investigate medical accidents, and that reimbursements for care be tied to providers' safety records.

"There's a reason that flying on a commercial airliner today is safer than walking," Quaid explains. "It's because when an accident happens, the NTSB makes a determination about what happened. Airline executives know they need to solve the problem quickly, whether it's a change in design or a new piece of technology, or people aren't going to fly their airline."

T. Boone and Z.G. are nearly 3 now and show no signs of lasting damage from the overdose. After nearly losing them, their parents make family time a priority, as the jungle gym, the tricycles, the toys, and the playhouse in the yard of their home suggest. In the twins' honor, Quaid will continue to speak out about medical errors. "And Kimberly is just as much a part of that," he says. "I go out and give speeches, and she holds down the fort." When T. Boone and Z.G. are older, the couple will tell them what they went through. "This is their legacy," Quaid says. "They're really tough, and they should be proud. Because of what happened to them, they already have saved lives."