When actor Dennis Quaid’s 12-day-old twins developed infections in 2007, he and his wife took them to a Los Angeles hospital. But a medical error nearly killed the babies when they received 1,000 times the intended dose of heparin.

Look-alike packaging on the 10,000-unit strength and 10-unit strength vials of heparin and a failure to keep the higher-concentration vials out of patient-care areas contributed to the mistake, patient safety experts said.

Yet the same error had occurred only 14 months earlier at an Indianapolis hospital, when six infants got heparin overdoses and three of them died. The case received widespread news coverage, but it was not enough to spare the Quaid family its ordeal.

Quaid says hospitals should not need to see a serious error in their own facilities before taking preventive action to protect patients. He has joined with patient safety and aviation experts to call for an agency akin to the politically insulated, independent National Transportation Safety Board to investigate cases of medical harm and report deidentified findings to physicians, hospitals and the public.

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