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Hospital Pharmacy Error Leads to Fatal Overdose in Newborn

prescription errorThe difference between milligrams and micrograms is a life-saving or life-threatening one. In the case of a premature 14-week-old baby needing a nutritional supplement, it was a fatal difference.

Pam Goff, lead pharmacist at Summerlin Hospital Medical Center had received a doctor's order for 330 micrograms of zinc to help boost the baby's metabolism. But when Goff entered the order into a machine that mixes the compound, she entered milligrams — the wrong unit of measurement — on the computerized menu, according to ABC News. The computer and other 'checks-and-balances' designed in hospital protocol should have caught the error, but they didn't.

Portfolio Magazine reported that in 2006, Summerlin Hospital had reclaimed pharmaceutical operations from an outside company — the third such one in 10 years. At the hearing, Goff testified the pharmacy was short-staffed the night the infant received the fatal overdose. 

That night, two fellow pharmacists failed to check Goff's data entry. A safety stop on the mixing machine had not been set, and a technician reading the order had replenished the machine 11 times with zinc; using 48 vials of zinc total to fill the baby's nutrition. Nurses didn't notice that the nutrition bag was much larger than normal.

In sworn testimony, Goff said that the unusually large size of the nutrition bag should have been noticed. "That intravenous bag was four times the size of Alyssa."

The Nevada Pharmacy Board fined Summerlin Hospital pharmacy $10,000, fined Goff $5,000 and placed the pharmacist on one year's probation. Two other pharmacists were fined $2,500 and given 30-day suspensions.

Summerlin Hospital settled with the parents of the newborn and said, "Everyone at the hospital was heartbroken by this tragic event, and words have not been adequate to express our sorrow...We've implemented very focused changes at the hospital to ensure this never happens again." News reports state that Goff now wears a tattoo on her wrist as a reminder of the infant's short life.

Although this prescription error occurred out-of-state, our North Carolina medical malpractice attorneys wanted to highlight it as an example of how carelessness is not always the error of one single person. Multiple members of the hospital staff were accountable and other safety protocols were not followed properly. Compensation is available when an innocent person and loved ones, such as the baby and the parents in the case above, suffer as a result of another party's wrongdoing. Of course, medical malpractice claims must fall within North Carolina's statute of limitations, among other factors. Everything you might want to know about malpractice claims in North Carolina is likely found in Brent Adams' book, available for free to all individuals who believe they have suffered as a result of medical malpractice. Click the link to the right of this page to order a copy, or click here for a confidential consultation with one of our North Carolina medical malpractice attorneys.