Wrong dosage kills toddler at Shands

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

Sebastian Ferrero died Oct. 10 at Shands at UF Medical Center, two days after a routine test to help doctors determine why his growth was below average.

Instead of receiving the prescribed 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 Dr. Donald Novak, vice chairman of clinical affairs for the UF College of Medicine pediatrics department.

The boy showed signs of distress while he received the medication through a catheter, and the procedure was halted, according to Novak. But it was continued after a doctor examined him.

A pharmacist and a nurse have been placed on administrative leave, Novak said.

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

A spokesman for the family told the Gainesville Sun that the boys parents "are appreciative of the fact that Shands and the University of Florida have taken the high road in this case."

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

[Last modified October 26, 2007, 00:35:26]