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A miscalculation in a prescription for Zinc slipped through the hands of three pharmacists and several nurses at a Las Vegas hospital and led to the death of a premature baby girl last fall. The error prompted the hospital to implement several changes to its policy and procedures for filling TPNs.
"This is a tragic case," said Kasey Thompson, Pharm.D., director of patient safety at ASHP. "The primary outcome from this event must be that the same error never happens again to another patient at any organization. This case should serve as a wake-up call to every hospital to immediately look at their processes to determine whether a similar error could happen in their organization."
The error leading to the death of three-week-old Alyssa Shinn on Nov. 9 certainly served as a wake-up call to Summerlin Hospital Medical Center, the facility where the mistake occurred. Changes there began the day after the infant's death, starting with a staff meeting and an internal investigation, according to testimony before the Nevada State Board of Pharmacy. That investigation prompted the hospital to hire a pediatric pharmacist and make changes to its policy on Total Parenteral Nutrition (TPN) orders.
The breakdown that resulted in Alyssa Shinn's death began with the mishandling of the infant's prescription by hospital pharmacist Pamela Goff. In her testimony to the pharmacy board, Goff tearfully admitted she selected the wrong unit of zinc for the infant's TPN IV bag, choosing 330 mg rather than 330 mcg-a dose 1,000 times larger than Shinn's neonatologist had ordered. However, Goff told board members, the TPN orders-particularly those from the neonatal intensive care unit-were written in quantity per volume of the IV bag's contents rather than quantity based on the patient's weight. Richard Harris, a Las Vegas attorney representing Shinn's divorced parents Kathleen and Richard in settlement discussions with Summerlin, criticized the hospital for failing to require all TPN prescriptions to be written the same way.
Hospital officials did not respond to repeated requests for comment. Goff and the two pharmacists who failed to catch her mistake were each fined $2,500 by the board and ordered to undergo additional training. The hospital itself was fined $10,000-the maximum the board can levy-and the pharmacy was required to undergo an evaluation to determine ways it can improve operations.
One improvement Kathleen Shinn would like to see has more to do with compassion than with hospital procedure. "After Alyssa died, we were offered no condolences, no grief counseling or spiritual counseling. They didn't offer to pay for her funeral," she said after the hearing. "We just left that night and never heard from them again. We would like to see not only improved safety, but compassion and caring. Let us be there. Let us hold her. If you know she's going to die, let us be there with her."