A boy is tested for growth hormone deficiency using a routine arginine test. What happened next is tragic. (via Medpundit)
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The fix is all window dressing. So they will have two docs sign off on the dose of this med, which probably represents one of a million doses of meds given in that facility every year.
Systems changes are all the rage and certainly should be addressed. Did the label on the bottle from the manufacturer unambiguously describe the concentration and total dose present in the bottle? Did the pharmacy computer system check the dose against standards to see if there was a significant deviation from the norm?
In the end people have to assume responsibility for their own goofs. If the order is unambiguous and the bottle is unambiguous then it is hard for the pharmacist point the finger anywhere else.
I guess I will just accept the fact my child is short.
Any pediatrics people here? How does 60 g of arginine (protein) kill someone?
I understand the huge dosing error but what exactly happened to the poor child?
If the nurse and the pharmacist were both put on Administrated leave, why wasn’t the Doctor, who was called when the infusion was stopped, part way through, because the child was ill, not also put on administrated leave? It doesn’t tell us what amt. he had already received, but if this Doc would have checked things out better when the little boy got sick, and stopped the infusion (instead of having it restarted) maybe that would have made a difference in the entire outcome.
What were the results of the autopsy?
If the dose was 10X the amount ordered, did the vial indicate that a 1/10 dilution was to be infused?
I have to assume that this was not the first time the test was administered at this facility. So, one must ask if the source of the amino acid was the same as was used previously without any adverse side effect taking place…
What was the pH of the arginine ( 60 g) that was infused?
Recall that arginine is a very basic amino acid, not a protein.
I hate hearing stories like this. There’s really no excuse, in my opinion. Three different people didn’t actually look at the bottle, essentially, for this to happen.
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