Medical Errors

[GatorMD60]

I thought that you all should check out this web site about a medical error that killed a healthy little boy...

sebastianferrero.org


Check it out. It's sad, but the family is making a positive out of it.

 

[GatorMD60]

Here is the story from the Miami Herald, incase you would rather not follow the link:

Toddler's death leads to stricter medical safeguards​

BY FRED TASKER
At age 3, Sebastian Ferrero was an active, healthy, intelligent boy who already spoke English, Italian and
Spanish and was attending preschool, his parents say.
On Oct. 10, he died at a Shands HealthCare facility at the University of Florida. Doctors say it was
because he was given a dose 10 times too high of a substance used for testing growth hormone deficiency
-- even though the boy's mother was present and questioning the dose as it was being administered.
In his death, Sebastian's grieving parents are praising at least the facility's candor in taking responsibility
and vowing to work with Shands on a foundation to build a ''state-of-the-art children's hospital'' with
safeguards to prevent such mistakes.
In a statement released late Friday, the family said: ``For the rest of our lives we will thank God that we
enjoyed Sebastian fully while he was on loan to us. This tragedy has taught us that we need to live like
him, genuinely and intensely, because we are here just in transit.''
Drug overdoses and other medical errors are a national problem, experts say. Across the country, hospital
patients on average experience one medical error per day of stay, injuring 1.5 million patients a year,
according to a 2006 investigation co-chaired by Dr. J. Lyle Bootman, pharmacy dean at the University of
Arizona, for the Institute of Medicine, a Washington-based research group.
''Hospitals are realizing they must take a stronger stand against errors,'' he said. ``The key is
communication among all the parties involved. We need check-and-balance systems to prevent confusion.''
A 1999 study for the same group said 44,000 to 98,000 people die in hospitals each year from such errors,
at a cost of $29 billion in additional care and lost productivity.
At a Thursday press conference in Gainesville, Dr. Donald Novak, professor of pediatrics and vice
chairman of clinical affairs for the UF College of Medicine's Department of Pediatrics, said: ``We take full
responsibility for Sebastian's death and are very, very sorry.''
Dr. Richard Bucciarelli, interim chairman of the UF College of Medicine's Department of Pediatrics, said:
``We will be most delighted to work with the family on these issues.''
Bucciarelli said the hospital is working out a settlement with the family, but that he couldn't reveal how
much.
In the press conference and a subsequent news release, Novak gave this account of the boy's death:
• On Oct. 8, Sebastian, healthy but small for his age, went to the University of Florida Physicians Pediatric​

​

Outpatient Clinic for a growth hormone stimulation test. He was given an amino acid called arginine to
test for growth hormone deficiency. It was dispensed by the Shands Medical Plaza Outpatient Pharmacy.
• The dose prescribed by the boy's doctor was 5.75 grams. Sebastian received 60 grams, even though the
boy's mother questioned the procedure as it was going on and Sebastian was showing signs of distress and
a headache.
The clinic had two bottles for Sebastian's test. And while the prescribed dose of 5.75 grams was printed on
each bottle, each bottle contained 30 grams of arginine. The bottles were marked ''1 of 2'' and ''2 of 2,''
which may have led the clinic's staff to think both bottles had to be given to Sebastian.
• That night, Sebastian was taken to the emergency room vomiting, and doctors determined he had
cerebral edema, a swelling of the brain. On Thursday, he was removed from life support.
Novak acknowledged a series of errors in how the arginine was processed by the pharmacy and
administered in the clinic, and outlined countermeasures:
• The hospital placed a nurse and pharmacist involved on administrative leave during an investigation.
• It put a moratorium on such procedures at all outpatient clinics. It is setting up mandatory retraining for
all personnel. It will create a double-sign-off system to cut drug errors.
''We mean to have experts look at all areas of our practice and review all of our policies,'' Bucciarelli said.
''Unfortunately,'' Novak said, ``these steps cannot undo the tragedy that occurred. Words cannot describe
our profound regret for these events.''
In Miami, attorney Tania Cruz, of Squire, Sanders & Dempsey, representing the family, said Sebastian's
parents, Horst and Luisa Ferrero, ``are handling it the best they can.''
``They appreciate that Shands has taken the high road in admitting liability. They want to use this tragedy
to create a legacy in their son's name, working with Shands to create a children's hospital.''
In the 2006 investigation for the Institute of Health, a major conclusion was that medical errors result not
from ''bad-apple'' medical workers but from ``faulty systems.''
In 2003, the University of Miami School of Medicine/Jackson Memorial Hospital set up a Center for
Patient Safety to cut the rate of errors. New classes there for interns and students put emphasis on
communication, said Dr. David Birnbach, professor of anesthesiology and director of the center.
``It's communication between nurse and doctor, between nurses, between doctors. We bring students
together to work on communication problems using mannequins and model patients. Then we show them
what they did wrong and show them how to do it right.
``I can't say we've cut all the error rates, but we clearly have improvements.''​