All Knucklehead Day Award Eighteen
This award should make you want to vomit.
Our 18th winners are The University of Florida's(UF) Pediatric Clinic at the Shands Medical Plaza, Dr. Don Novak The Medical Director of the Clinic and Alan Knudsen, director of pharmacy services for Shands at UF and Dr. Janet Silverstein. They all get the award for failing Sebastian Ferrero and his family. Sebastian died after being administed medicine at Shands, ten times over what was prescribed for the three-year-old boy.
Read the entire Gainesville Sun article below. This is a tragedy, and my heart goes out to the Ferreros. My wife and I lost a son. Dr. Novak and Shands are taking measures to prevent this from happening, but excuse me that doesn't let these people off for what they did to Sebastian.
Another point- The hospital suspended a nurse and pharmacist, but not the doctor who failed to check the medication or Dr. Silverstein.(That's assuming two different doctors administered the medication, w hich may or may not have happened. Dr. Silverstein is not let off the hook if another doctor administered it, for she prescribed the dose) Doctors need to be held accountable, unfortunately hospitals prefer to let them off the hook. Look what a hospital here in Palm Beach County did. Rather than fire the doctor who made a medical blunder, they fired the person who reported it. What are you trying to cover up Dr. Novak? Are there other children your facility has killed or disabled? Then why wasn't the doctor suspended too? Heads should roll, and Novak should be at the front of the line for only taking action afterwards. You and your staff killed Sebastian Ferrero and all you can say is you're sorry and suspend a few people. Resign and fire everyone who had a part in this affair, and that includes supervisors.
For medical incompetence and administrative blundering before and after a three-year-old boy's death, The University of Florida's(UF) Pediatric Clinic at the Shands Medical Plaza, Dr. Don Novak The Medical Director of the Clinic, Alan Knudsen, director of pharmacy services for Shands at UF, and Dr. Janet Silverstein are today's 18th Knuckleheads of the Day.
Linked to- Big Dog, Right Wing Nation, Stop the ACLU, Third World County, Woman Honor Thyself, Rosemary,
Three-year-old Sebastian Ferrero of Gainesville was a healthy, happy youngster who happened to be short for his age.
His parents, Horst and Luisa Ferrero, took him in to see physicians at the University of Florida, asking whether he might be a candidate for growth hormone therapy to give his height a boost.
On Oct. 8, they took him to UF's Pediatric Clinic at the Shands Medical Plaza for what was to be a routine test to see why his growth rate was below average.
Two days later, after a series of tragic errors, Sebastian was dead.
Health-care officials from UF and Shands gathered for a news conference Thursday to issue an apology to the family, explain what went so terribly wrong, and to promise they'd take steps to assure the same mistakes wouldn't happen again.
"To his mom, dad, younger brother and other family members, we extend our prayers, thoughts and deepest sympathies.," Dr. Don Novak said. "We take full responsibility for Sebastian's death and we are very, very sorry."
Novak is medical director of the UF Pediatric Clinic and vice chairman for clinical affairs in the College of Medicine's department of pediatrics. He was joined by Dr. Richard Bucciarelli, interim chairman of the department; Alan Knudsen, director of pharmacy services for Shands at UF; and Jane Schumaker, who heads UF's faculty group practice.
Here's what Novak said happened when Sebastian kept his appointment at the pediatric clinic.
At the clinic, he was given an infusion of the amino acid arginine, used to test for growth hormone deficiency.
Both the test and arginine are considered safe under normal circumstances, Novak said.
The dose prescribed by his physician, Dr. Janet Silverstein, was 5.75 grams and the prescription was processed by the Shands Medical Plaza's outpatient pharmacy. Sebastian actually received 60 grams - more than 10 times the correct amount.
Sebastian's mother asked if the dose was correct before the test was begun, Novak said. It took 30 minutes for the infusion of arginine in solution to drip into his veins. About three-fourths of the way through, Sebastian developed a severe headache.
Headaches can be a side effect of the procedure, Novak said. His father asked that the procedure be stopped and Sebastian was examined by a physician.
The doctor checked Sebastian's chart, but not the bottle of solution. The procedure continued.
Sebastian was released and his family took him home.
About 11:30 that night, when they brought him to the emergency room at Shands AGH, Sebastian was disoriented and vomiting. He was transferred to the pediatric intensive care unit at Shands UF early on Wednesday. On Wednesday evening, Oct. 10, he was declared brain dead. His family was informed then that he had received an overdose of arginine, Novak related.
"Our investigation to date has identified a series of errors that collectively caused this tragic outcome," Novak said, and the family has been made aware of our findings.
"We are continuing to investigate and the results of that investigation will be fully disclosed."
Here's what the health-care officials say happened after the test was ordered for little Sebastian.
* The pharmacy at the medical plaza received the doctor's order, but since it doesn't stock arginine, ordered two 300-milliliter bottles from the supplier.
* The correct dosage - 5.75 grams - was printed on the bottles, but the bottles were labelled "1 of 2" and "2 of 2" by hand.
* That may have lead clinic staff to think both bottles were needed for Sebastian's infusion, according to Novak, even though his mother asked if that was the case. In fact, all that was needed was about one-sixth of one bottle.
* The nurse did not show the doctor the bottle before starting the infusion.
Novak outlined a number of steps that have already been taken to safeguard against a similar tragedy, including:
* Putting the nurse and pharmacist directly involved on administrative leave.
* Placing a moratorium on infusion of drugs in all outpatient clinics.
* Instituting a double sign-off system so that two qualified professionals check to be sure the right patient receives the right dose of the right drug.
* Developing a mandatory training program for clinic staff to be completed within the next two weeks.
The pharmacy will deliver only customized doses of arginine in the future, and children scheduled to receive the arginine test will get it in a dedicated infusion center, he added.
"These steps cannot undo the tragedy that occurred," Novak concluded.
Shands and UF officials said that the Ferrero family had asked the media to respect their privacy and not to contact them. The Ferreros apparently reached an out-of-court settlement in the case.
Luis Diaz, a close friend of the family, spoke briefly to The Sun Thursday. He said Sebastian's parents are still too emotionally distraught to talk about their son's death.
"He was a beautiful, healthy boy," Diaz said.
Horst and Luisa Ferrero have one surviving son, Sergio.
"They are appreciative of the fact that Shands and the University of Florida have taken the high road in this case," Diaz said.
"Their concern now is that all the necessary steps are taken so that this can never happen to someone else's child."