UF and Shands HealthCare officials apologized Thursday to the family of a 3-year-old patient who died at Shands at UF from an overdose of an injected chemical earlier this month.
Sebastian Ferrero was prescribed 5.75 grams of arginine - an amino acid that detects a growth-hormone deficiency - but a nurse gave him 60 grams, a news release stated. Sebastian died Oct. 10.
"We take full responsibility for Sebastian's death and are very, very sorry," said Dr. Donald Novak, director of the UF Pediatric Clinics, standing beside blown-up pictures of the two nearly empty arginine bottles.
The nurse and pharmacist directly responsible for Sebastian's death have been placed on paid leave pending an investigation into their work, the release stated.
Sebastian's growth rate was below average for his age, and doctors were trying to see whether his pituitary gland was functioning correctly.
The pharmacist who filled the prescription was not familiar with the drug and was unsure how much was in a bottle, said Alan Knudsen, director of pharmacy services at Shands at UF. He wanted to make sure there was enough medicine to trace the hormone, so he used two bottles of the chemical, Knudsen said.
Doctors use arginine to test a deficiency of a growth hormone, which is secreted by the pituitary gland.
The drug is injected into the patient over 30 minutes, and after that, blood samples are taken at 30-minute intervals for three hours.
Complications from arginine testing, when done correctly, are extremely rare, the release stated.
Each bottle's label instructed the hospital to give 5.75 grams to Sebastian, which is about one-sixth of one bottle.
The pharmacist wrote "1 of 2" on one bottle and "2 of 2" on the other. The nurse assumed she was supposed to give the child both of the bottles' contents, the release stated.
Before nurses gave Sebastian the incorrect dose, his mother asked if the amount was appropriate, but nurses continued anyway, the release said.
About three-quarters of the way through Sebastian's infusion Oct. 8, he got a severe headache, the release stated.
A physician examined him, but because headaches can be a side effect of the procedure, the infusion continued.
Sebastian's parents took him home that afternoon, but at about 11:30 p.m., they brought him to the Shands emergency room because the side effects had not subsided.
Sebastian was treated for dehydration because he was vomiting, but doctors determined he had cerebral edema, or swelling of the brain.
Sebastian was declared brain dead and then removed from life support Oct. 10. Another child was given an excessive arginine dose earlier this year. That case was not recognized until Sebastian's case was investigated, Novak said.
The same nurse was involved in both cases, Novak said. She's worked at Shands for 14 years.
