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Hospital Pharmacy Error Leads to Fatal Overdose in Newborn

In a pharmacist’s world, there is a big difference between milligrams and micrograms. In the case of a premature baby needing a nutritional supplement, it was a fatal difference for a 14-week-old premature baby.

Pam Goff, lead pharmacist at Summerlin Hospital Medical Center n Las Vegas 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, reported ABCNews.com.p>

"I put in the 330 and when I went to pick the units, I grabbed 330 milligrams per decaliter instead of micrograms per decaliter," Goff said. In practically terms, baby Alyssa received 1,000 times the doctor’s prescribed dose.

When Richard and Kathleen Shinn returned to the hospital that morning, they knew there was something wrong with their baby.

"She was very lethargic," Richard said. "She was not moving at all and she was always feisty. What we were used to seeing were her legs and arms going, just a really energetic little girl. But now she wasn't moving at all. And the color was leaving her body."

That’s when nurses told the Shinns their baby had received an accidental overdose of an intravenous nutritional supplement.

For the pharmacist, it was a nightmare come true. I just broke down into tears and started to shake," Goff said. "I sobbed uncontrollably. I went back to my desk and started to vomit and cry and shake."

At a July 2007 hearing before the Nevada State Board of Pharmacy, Goff apologized publicly to the Shinns. "Nothing I could ever say would ease your pain. I know that," Goff said in court, turning to face Shinn. "And I want you to know that I'm really sorry."

Multiple Hospital Checks and Balances Failed

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 Alyssa received a fatal overdose. "It can make it very hectic and make it very stressful on everyone that's involved," Goff said.

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 TPN bag. 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 Shinns and said, "Everyone at the hospital was heartbroken by this tragic event, and words have not been adequate to express our sorrow to the Shinn family. We've implemented very focused changes at the hospital to ensure this never happens again."

Portfolio Magazine reported Goff wears a tattoo on her wrist as a reminder of Alyssa's short life. She hopes it will inspire her to "push forward every day for this little girl."

Since their daughter died, the Shinns have separated. Alyssa, who lived for just three weeks, is buried with other children in the hospital's "Garden of Innocence."

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