Pediatric deaths bring hospital unwanted attention

October 9, 2006

The entire pediatrics program at Stony Brook University Hospital in Suffolk County, N.Y., has recently come under scrutiny following the deaths of three children there between May and July of this year. On Aug. 14, the New York State Department of Health issued a cease-and-desist order against the hospital's pediatric cardiac surgery and catheterization programs, and on Aug. 18, the health department fined the hospital the maximum amount of $38,000 for 19 violations associated with these fatalities. An administrative court hearing at which the hospital may challenge the cease-and-desist order was scheduled for Sept. 28.

One of the incidents under investigation involved a drug overdose. On May 13, 11-year-old Amee Martin died after being given 27 times the correct dose of papavarine. The child was administered the anticoagulant while undergoing emergency surgery to remove a blood clot, the result of a physician mistakenly catheterizing the child's artery instead of her vein.

According to the state health department's report, the following lapses occurred in the operating room: The anesthesiologist-and not a registered nurse, as is required-brought the drug into the operating area; a surgical technician-and not a registered nurse, as is required-handled the medication; the technician did not verbally verify the name and dose of the drug before handing it to the surgeon; and the technician and the surgeon did not confirm the dose prior to administering the drug.

"I think there should be more opportunities for clinical pharmacists and that hospitals could even expand their clinical pharmacy departments to have pharmacists at different locations, such as on medical/surgical floors," suggested Siu, who is also a clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in New Brunswick.

On Aug. 22, Amee Martin's parents filed a $30 million wrongful death suit against the state, in addition to the surgeon, anesthesiologist, two residents, nurse, and surgical technician who cared for the girl.

The other two incidents at the hospital involved a seven-year-old boy with Duchenne's dystrophy who died after routine adenoid surgery allegedly because the hospital had failed to adequately assess his heart and lung function, and a premature infant who died awaiting urgent cardiac surgery because the pediatric surgeon operated only once a week.

These three incidents have also prompted an investigation by the office of Suffolk County District Attorney Thomas Spota. Also, the Joint Commission on Accreditation of Healthcare Organizations announced in late August that it was sending a "special reviewer" to the hospital to investigate what it described as a "high-priority complaint."

On Sept. 7, the Centers for Medicare & Medicaid Services announced that it was opening its own inquiry. On the same day, Stony Brook University president Shirley Strum Kenny announced the appointment of a Blue Ribbon Commission to conduct a comprehensive review of Stony Brook University Hospital. The five-member panel was scheduled to begin its investigation on Sept. 18.

At press time, Stony Brook University Hospital had not responded to requests for comment.

THE AUTHOR is a clinical writer based in New Jersey.