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Overmedication Kills Tot; Gainesville Hospital Pays

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The Associated Press

Published: October 26, 2007

GAINESVILLE - A 3-year-old undergoing tests at a pediatric clinic died because he was given a dose of medication more than 10 times stronger than prescribed, hospital officials said Thursday.

Sebastian Ferrero died Oct. 10 at Shands at the University of Florida medical center, two days after a routine test was done to help doctors determine why the boy's growth was below average.

Instead of receiving the prescribed dose of 5.75 grams of the amino acid arginine, officials said, the Shands Medical Outpatient Pharmacy gave him more than 60 grams.

"We take full responsibility for Sebastian's death," said Donald Novak, vice chairman of clinical affairs for the UF College of Medicine department of pediatrics. "We are very, very sorry."

The boy showed signs of distress while he received the medication through a catheter, and the procedure was halted, Novak said. It was continued after a doctor examined the boy.

The Gainesville Sun reported the family reached an out-of-court settlement.

A pharmacist and a nurse involved in the case have been placed on administrative leave, and a moratorium has been instituted on all infusion procedures at all UF clinics until a quality assessment and new patient safety measures are implemented, Novak said.

Medication for intravenous infusions now must be reviewed by the pharmacy manager.

The boy's parents had an unlisted number and could not be reached for comment by The Associated Press.

The boys parents "are appreciative of the fact that Shands and the University of Florida have taken the high road in this case," family spokesman Luis Diaz told The Gainesville Sun on Thursday.

"Their concern now is that all the necessary steps are taken so that this can never happen to someone else's child."

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