Another death at Children's hospital investigated


by KING 5 News

Posted on September 30, 2010 at 4:32 PM

Updated Friday, Oct 1 at 11:11 AM

SEATTLE - The medical director for Seattle Children's hospital says a second infant died and one adult was given medication erroneously while under care of the hospital's staff.

The news Thursday comes just a week after it was revealed that one infant died recently at the hospital after staff administered an overdose of a drug.

Dr. David Fisher says the latest fatality involves an infant whose cause of death has not yet been determined, but who had been given medication without consulting a licensed prescriber.

"Our neonatal ambulance team was dispatched to another hospital to transfer a critically ill newborn to Children's for critical care. Against policy and scope of practice, a Children's staff member administered medications without an order from a licensed prescriber," said Fisher. "These medications are often administered in this dosage for infants that are difficult to ventilate or those who have unstable airways. However, our policy and procedures require that the staff member assesses the situation, relate this information to the physician, and administer the medication as per orders of the physician. The order step did not happen in this case."

Fisher says the third case was that of an adult who arrived in life-threatening respiratory distress at the hospital and was given the correct medicine and dose, but it was wrongly administered. That person has recovered.

Fisher says the hospital has reevaluated its entire medication delivery system. He also say that for one day, the hospital will be suspending all non-emergency operations like clinics and elective surgeries and use that day to review patient safety practices.

"As medical director, I take full responsibility and am accountable for patient safety. And, we take full responsibility for any weakenesses in our system," said Fisher. "Our mission is to provide excellent care for children. We failed in our effort to provide safe care, and we are devastated"

Fisher repeatedly tried to assure the public that there is no systematic problem at Children's, which has achieved national renown and respect for its work treating 1,000 of the sickest and most vulnerable kids every day.

"Children's is safe. The patients are complex. And please keep in mind that humans are involved," said Fisher.

A King County spokesman says Children's reported the second death to the King County Medical Examiner's Office on Tuesday.

The Washington state Department of Health says it just received the case this week. Because it's an open investigation, DOH says it can't comment further about specifics. It does say it has open complaints in the Nursing Care Quality Assurance Commission and the Facilities division. A facilities investigator was at the hospital Thursday.

"Any time a child dies or a patient dies unexpectedly, it's a tragic, tragic situation," said Tim Church with the Department of Health. "The Department of Health, the nursing commission and our facilities people want to connect with the hospitals because I know the hospitals just like the Department of Health want to find out why something like this happens and see what can be done to prevent it next time."

On Sept. 15, Kaia Zautner was given ten times the intended dosage of calcium chloride in the ICU at Children's. She died four days later.