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We've been reporting to you that risk managers, defense attorneys, physicians, and hospital and insurance company executives are "experimenting" with Sorry Works! on case by case basis to see how disclosure works. Last Fall we shared the story of Methodist Hospital in Omaha, Nebraska in which the hospital apologized for missing an aortic dissection in a young man during three different ER visits and worked with the family to produce an educational video that is being distributed to other hospitals (see this link:http://www.sorryworks.net/newsletter20070904-special.phtml).
Today we're reporting on a Florida hospital that apologized for the tragic death of a toddler and from this apology an effort has been launched with the family to develop a much-needed children's hospital. See the family's website at"http://www.sebastianferrero.org/"
Also, read two moving stories below, especially the first story in which the hospital did an A+ job of taking responsibility and describing how they were going to fix the problems so it wouldn't happen again (which is key for families!).
Shands apologizes for death of boy
By DIANE CHUN
Sun staff writer
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 Sebastia
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 supply. 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."
Gainesville needs a children's hospital
By MARCI SLAYTON, M.D.
December 23, 2007
On Dec. 6th, there was a grass-roots community meeting to discuss the need for a Children's Hospital in Gainesville. At this meeting were doctors, lawyers, teachers, social workers, business owners, parents and other interested members of our community.
The person running the meeting was Horst Ferrero, the father of three-year-old Sebastian Ferrero. As many Sun readers know, Sebastian died at Shands Hospital on October 10 following a medication overdose
Sebastian's parents have suffered an event that every parent dreads; the death of their child. Remarkably, his parents are trying to turn this tragic event into something positive for our entire community. They have started a foundation in their son's name whose sole purpose is to bring a free-standing children's hospital to Gainesville.
Last year, the medical administration at UF moved part of the Department of Pediatrics to Shands at AGH, while some pediatric services remain at the main Shands hospital. This has created a great deal of difficulty in our efforts to provide top-notch pediatric care. It is difficult for us as physicians to figure out which hospital is best for our patients. This is because some services are offered at one hospital and not the other.
It is even more difficult for the pediatric specialists who work within the UF and Shands system. The fracture of the UF Department of Pediatrics into two hospitals has hurt our ability to provide care to our smallest patients
Our sick babies and children wait for hours in the emergency department, only to be told that they are at the wrong hospital.
Critically ill children are being transferred from one hospital to the other just to get MRI scans done after 5 p.m. This is unacceptable.
There is no doubt that Gainesville needs a children's hospital. The pediatricians in our community have known this for a long time.
The best gift that Gainesville parents can give to their children is the gift of excellent medical care. Among the area pediatric practices that have joined in this effort are Alliance Pediatrics, Benton Pediatrics, Dr. B's Kids, Gainesville Pediatric Associates, Healthy Steps Pediatrics, Kids Doc Pediatrics, Landay Pediatrics, Milla Pediatrics, Pediatric Group of Gainesville, The Kids' Health Team, Tumarkin Pediatrics and Worthington Pediatrics.
Every pediatrician from those offices are in complete agreement that it is time to start planning for a free-standing children's hospital.
We would be happy to discuss this issue with parents and community leaders. Log on to http://www.sebastianferrero.org/ for more information.
Marci Slayton is a Gainesville pediatrician.
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