Hospital pharmacy fined $10,000 for zinc overdose death

August 20, 2007

The Nevada State Board of Pharmacy has fined a Las Vegas hospital $10,000 and suspended three of its pharmacists for errors that have led to the death of a premature baby last fall.

The Nevada State Board of Pharmacy has fined a Las Vegas hospital $10,000 and suspended three of its pharmacists for errors that have led to the death of a premature baby last fall. The board, after conducting a hearing late last month, fined each of the pharmacists $2,500 and ordered them to undergo extra training. The board is now preparing a report that will be sent to the state's nursing board on the Nov. 9, 2006, death of Alyssa Shinn in the neonatal ICU of Summerlin Hospital Medical Center. The nursing board will determine whether nurses who cared for Shinn should be punished for failing to notice her IV food bag contained too much zinc. Shinn was three weeks old when she was given a dose of zinc 1,000 times larger than what her doctor had ordered. A pharmacist incorrectly entered the wrong amount of zinc into a hospital computer, and the lethal dose was added to the IV solution that was her only source of nutrition. Two other pharmacists, a pharmacist technician, and nurses in the hospital's neonatal ICU failed to notice the error.

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