QUALITY: In Good Company: Dennis Quaid and Preventing Medical Errors

Imagine if your newborn twins, already hospitalized with an infection likely acquired at another hospital, were given two potentially fatal overdoses of a blood thinner. Imagine if your pediatrician (now your former pediatrician) did not call to tell you. Imagine if the night nurse told you everything was fine when you phoned to check on the babies. Imagine if you learned the truth when you arrived at the hospital at 6 a.m. to see your kids and were met by Risk Management.

That's what happened to Dennis Quaid last winter. His babies survived. His story has been told. But Quaid hasn't forgotten the 41-hour ordeal, when his tiny children nearly bled to death, their blood "squirting on the walls." He has joined the ranks of "cause celebrities," knowing that his fame can bring national attention to medical errors that usually occur in isolation. He has set up a new foundation to address patient safety, particularly regarding medication errors.

Quaid told the Association of Health Care Journalists' annual convention that he used to think of hospitals as safe places. Now, he said, "I would never let a friend or family member ever be in the hospital alone." Not because the doctors or nurses are incompetent or uncaring, because by and large they are not, he said. But they are human. They make mistakes. And the safeguards aren't in place--or aren't consistently used--to prevent those mistakes. Lawmakers have been grappling with how to address quality and errors without spurring more malpractice litigation; so far they have not agreed on answers.

As a movie star, Quaid doesn't profess to have all the answers, or even to have the policy expertise to ask all the questions. But he said he doesn't understand why hospitals can't adopt some of the same technology--like bar codes on medications to prevent errors--that are commonplace in supermarkets. A licensed pilot, he said he doesn't understand why medical errors aren't studied the way aviation errors are, to prevent a repeat catastrophe. He doesn't understand why it took a week and a half to get his kids' medical records, 300 pages each, only to find three pages missing, covering the critical nine hours when the errors were made.

Only one event in the whole long nightmare didn't surprise him: the hospital never sent a bill.

The policies Quaid calls for are not only reasonable; they're starting to be implemented.

The Institute of Medicine found in its 1999 report, "To Err Is Human," that as many as 98,000 Americans die each year from medical errors. Since then, the Institute for Healthcare Improvement launched its "100,000 Lives" campaign aimed at promoting hospital safety around the country (and in 2006, after initial success, they expanded their goal to 5 million lives). Leading edge systems like Geisinger in Pennsylvania and the Mayo Clinic in Minnesota have adopted a "Never Event" policy of not taking reimbursement for extremely serious and preventable errors that occur in their systems. Similarly, Medicare recently announced that it will no longer pay for a number of specific preventable medical errors.

These efforts would be made more effective by comprehensive reform which would combine and amplify the incentives for developing health information systems, providing payment incentives and sharing best-practices among all clinicians.