Four months ago, 6-day-old Gianni Vargas was the victim of a medical mishapat Stony Brook University Hospital. The newborn died of a medication overdosethat started with a missing decimal point on a prescription pad.
But, State Health Department officials say that the mistakes did not stop there.A recent investigation found glitches at numerous levels of operation. Breachesof hospital policy and blatant medical errors snowballed and culminated in thetragic death of an infant whose prognosis, before the medication was administered,was good.
The report indicated that after the nurse practitioner prescribed the lethaldose, an unlicensed and virtually unsupervised technician was allowed to fillthe order, in direct violation of state law. A nurse then administered the medicinewithout the sanction of the attending physician.
The child was given ten times the amount of potassium chloride someone hisage should have received. The drug was being used to treat what the hospitalgenerally classifies as a ‘mild’ potassium deficit, which the HealthDepartment said did not even require intravenous medication according to thehospital’#146;s own policy. The infant could have been treated with a smalloral dose of potassium chloride.
In 1995, a similar incident occurred at the facility when another baby, PetraMorgan Fiel, was given 10 times the proper dose of morphine.
Rob Kenny, a spokesman for the state Health Department said that officialsare taking the Vargas case very seriously because of the tragic outcome andthe fact that it was a repeat violation. No fines have yet been implemented.
David Raimondo, the Lake Grove attorney representing Ana Celina and GiovanniVargas, Gianni’#146;s parents, called the Health Department’#146;s report as’a bombshell’ that described the ultimate failure of the system institutedto protect human life.
Stony Brook Hospital released a statement in response to the report, assuringthat they have been taking steps to ensure patient safety. These measures includethe establishment of a safety committee and increased technology in the pharmacy.Hospital spokesman Dan Rosett described the steps as ‘comprehensive.’
The report scrutinized every department, and spared none. The administration,medical staff, and nursing services all came under fire for unsafe practices.Chief executive Bruce Schroffel was blamed for not creating and utilizing appropriatepersonnel practices. Most significantly, he was faulted for failing to orientnew registered pharmacists with regards to providing care to neonatal patients.
The crux of the investigation, however, was the understaffed pharmacy and thedeficiencies of its technology. According to the report, during a tour of thepharmacy by state health officials, a pharmacist was told to enter a faultyorder for potassium chloride that was ten times greater than the prescribeddose for an infant. The computer did not identify the mistake, and the pharmacydirector acknowledged that the program cannot identify dosing errors for childrenless than thirty days old.
Supervision of pharmacy technicians had been loose because of understaffing.The report indicated that it was commonplace for unqualified personnel to mixintravenous solutions without adequate supervision. These solutions were thenadministered to patients without ever being verified by the pharmacist.
The report noted that the pharmacy staff had lacked one pharmacist for an extendedperiod and asserted that this may have factored into the death of Gianni Vargas,as and unlicensed personnel was called upon ‘to function beyond his scopeof practice.’
Upon review by the state, 81 medication ‘incidents’ were identifiedover a six-month period in 2001. During that time, three medication overdosesinvolving infants were specifically noted.
