tragic error
hospital mistake kills newborn after heart surgery
by barbara j. durkin
staff writer
february 8, 2002
http://www.newsday.com/news/local/longisland/ny-libaby082580284feb08.story?coll=ny%2dtop%2dheadlines
giovanni and ana celina vargas had never held their newborn baby boy, never seen both his eyes open, when they were summoned to the neonatal intensive care unit at stony brook university hospital on tuesday morning.
they stood in shock as the doctor who had performed life-saving heart surgery on their son just two days earlier told them 6-day-old gianni was dead.
"he told me they made a big mistake," giovanni vargas said. "my baby was dead and he didn't understand what happened."
the couple said stony brook officials told them the next day that their son had accidentally been given a lethal dose of intravenous potassium chloride, 10 times more than he should have gotten, apparently because of a missing decimal point on a prescription.
the state health department said it is investigating the death, and stony brook is conducting its own investigation. david raimondo, the couple's attorney in lake grove, said he would file a notice of their intent to sue today.
"we are sincerely sorry and extend to the grieving family our heartfelt condolences," bruce schroffel, the hospital's director and ceo, said in a written statement. "in spite of numerous safeguards, an error occurred resulting in the tragic loss of a life. we are conducting a thorough investigation of this baby's death to determine what steps are necessary to ensure that this will never happen again."
the brentwood couple, both 27, said they were told by hospital officials that a prescription for potassium chloride read 35 instead of 3.5 and nobody picked up on the mistake.
"everything was checked by professionals at each of three different steps of the process," schroffel said. "we have now doubled the number of professionals at each step."
but the family still doesn't know who wrote the prescription and who administered it. and schroffel yesterday declined to comment on whether staff were disciplined in the wake of the death.
"they told us what happened but they didn't tell us what failed," raimondo said.
yesterday, in their attorney's office, ana celina and giovanni vargas, who married last april, struggled for answers.
giovanni vargas, an ironworker who had been working at ground zero until he was laid off about a month ago, seemed composed as he recounted their son's brief life. though there were people there to translate her words from spanish, ana celina sat mostly silent in despair.
early in the pregnancy, doctors had detected that gianni had a heart valve problem that would require surgery at birth. with a high-risk pregnancy, ana celina vargas went to stony brook weekly, where the couple believed she received good care. "i thought we were in good hands," said giovanni vargas. "i guess we were wrong."
it was a stressful time. "we thought we were going to lose the baby," said giovanni vargas. "i was always asking, do you think we're going to lose this baby? it was a question i couldn't stop asking."
gianni was born by emergency caesarean section jan. 30, full-term, weighing nearly 8 pounds. the heart valve problem was not as serious as doctors had believed, giovanni vargas said.
"he looked great," said vargas, describing a little boy with his mother's coloring, ears and nose and his daddy's straight dark hair.
instead of operating immediately, they put gianni on medication and scheduled the surgery for feb. 3.
the surgery was deemed a success and the hospital staff promised the couple they would soon be bringing their son home. the baby was being given potassium chloride because he had a potassium depletion and they needed to regulate his fluids.
the couple stayed with their son until about 8 p.m. monday. shortly before they left, giovanni vargas saw his son open one eye just for a moment.
that night, ana celina vargas dreamed that something terrible happened to gianni, she said. early the next morning, they got the call: their baby had taken a turn for the worse and they should get there as soon as possible.
"is my baby dead?" vargas said he asked, to no answer.
now the couple wants answers: who wrote the prescription, who gave it, why didn't anyone notice that it was far too much for a baby?
a study in 1999 estimated that medical errors kill about 44,000 to 98,000 people in u.s. hospitals each year, with medication errors the most common problem. a report by the joint commission on accreditation of healthcare organizations, which surveys hospitals across the country, found that potassium chloride was the most frequently implicated drug in medication errors they investigated.
in recent years, there has been much discussion about setting up systems to prevent such errors, said arthur levin, who heads the center for medical consumers, a nonprofit advocacy organization in manhattan.
"if the right system is in place this would not happen," levin said. "there's no excuse for it.... maybe this is an isolated case, but let the hospital tell the public what it's doing [to prevent such cases] and how this happened."
that's what the vargas family wants. "i want to make sure this doesn't happen to any other kids," giovanni vargas said.
the couple sat yesterday with a soft purple keepsake box between them. the hospital had given it to them, filled with the outfit gianni was wearing when he died, a card with his tiny footprints and two photos of him taken after his death. the pictures of him alive had not yet been developed. too much had happened too fast.
on tuesday, ana celina vargas held her baby for the first - and last - time. she clung to him for more than two hours. giovanni vargas didn't want to see his son dead. but by mistake, he turned around and saw him.
"i hugged him for like five, 10 minutes," he said. no, his sister, gently told him. "it was 45 minutes," ivelisse vargas said. "you didn't even realize it."
copyright © 2002, newsday, inc.
bells rang in my head just reading this...20 meq adult standard...35 meq unusual, but for a baby would automatically think too much and i've never worked peds/nicu!
no one questioned this, can't believe it, must have been on autopilot...prepared by nursing or pharmacy??????????
how many hours working, ot?
many system problems here. who administered?
another nurse with license at stake, but what will be done to the doctor???
