Hope Springs From A Deadly Medical Mistake

Parents Of Fla. Boy Killed By Hospital Error Start Foundation To Prevent Similar Accidents

(AP)  Horst and Luisa Ferrero took their intelligent, healthy and happy 3-year-old, Sebastian, in for a medical exam last October. Two days later he was dead, killed by a series of medical errors that began with a massive drug overdose.

Sebastian's parents have formed the Sebastian Ferrero Foundation in the hopes of preventing similar accidents. They plan to give it the $850,000 settlement they received from Shands Healthcare at the University of Florida.

"We never thought there was a risk involved," said Horst, 33. "This was something preventable and this was something simple. This was a routine test."

The Ferreros hope to build a $300 million, 125-bed standalone children's hospital in Gainesville within five years. They estimate they must raise about 10 percent of the money - $30 million - with the remainder coming from bonds.

The couple, who are developers, believe if Sebastian had been treated at such a hospital, the cascade of mistakes that led to his death might have been avoided, or at least caught in time. The Institute of Medicine estimates that as many as 98,000 people die each year in U.S. hospitals due to medical injuries.

Although their son died after being treated at Shands University of Florida hospital and Shands AGH, both in Gainesville, the boy's parents hope the new hospital would be operated by Shands. It operates a children's hospital within the UF hospital.

"It will depend how involved the community gets and how committed UF and Shands are to make this a reality," said Debbie Joseph, the foundation's executive director.

The tragedy began when the Ferreros took Sebastian to the University of Florida Pediatric Outpatient Clinic for a routine growth hormone stimulation test suggested by his physician.

At 25 pounds, the boy was small for his age, and the doctor wanted to see if he might be a candidate for growth hormone therapy.

Sebastian's 32-year-old mother told him about the test, and said it would feel like a mosquito bite. She bought a portable Thomas the Train set to entertain him.

The test involved the infusion of the amino acid arginine into his veins. His physician prescribed a dose of 5.75 grams, but the prescription processed by the Shands Medical Plaza's outpatient pharmacy was 60 grams.

Hospital workers administered the dose, and did not realize the error even when the parents asked them to check their son, who developed a headache and appeared to be in extreme pain.

The parents took him home, but when he vomited and had seizures they brought him to the Shands AGH emergency room, where they waited four hours for the boy to be seen.

He was later sent to a pediatric intensive care unit, and a CT scan was misread because there was no pediatric radiologist on duty, the Ferreros said.

By the time he was transfered to the intensive care unit at Shands at the University of Florida, the boy was brain dead.

The Ferreros soon learned from their physician that the overdose was the cause of Sebastian's death.

Shands immediately admitted its errors caused Sebastian's death and its investigation uncovered another arginine overdose: The mother of a 5-year-old boy stopped a test when her son jumped off the couch screaming, "My brain is on fire."

It implemented a series of changes, including the establishment of an infusion center with specially trained nurses. It will order its own medication and fill its own prescriptions, said Dr. Mike Gold, the College of Medicine's senior associate dean for clinical affairs. The hospital also will increase its training and oversight.

Gold said building a new children's hospital would likely take several years, or even a decade. But he admires the Ferreros' efforts.

"I cannot imagine a worse tragedy than for a parent to lose a child," Gold said. "But they are taking what happened to Sebastian and trying to make the world a better place."

[dr_slayton]

As a pediatrician in Gainesville, Fl, I have come to the painful realization that children get "the short end of the stick" when it comes to quality medical care. The errors that lead to little Sebastian Ferrero''s death are unforgivable. Yet, at the same time, I can see how all the lapses in care came to be.

Children are not little adults. Pediatricians know this intuitively, but others in the medical field do not. If Sebastian had been treated at a children''s hospital, I believe the pharmacist would not have made such a grave error in the dose of Arginine and the nurse in charge of Sebastian would have known, intuitively, that the dose of medication was wrong.

I am amazed by the grace and courage of Sebastian''s parents. I hope to be a part of their dream...to make medical care safer for ALL children.

Dr. Marci Slayton

[ptmars1]

My partner and I have also started a Non-profit organization, all for CHILDREN with spinal cord disorders. Every comment sheds new light on everything we are doing.If every single nurse, doctor, parent and patient checked everything twice we might not have this problem. Each doctor needs to double check what he writes, and sign it twice, and then every nurse needs to double check him. There should be some sort of computer system set up, for double checking. Some one needs to come up with something, as we are loosing too many people, and children to this huge mistake.
We can blame the nurses and the doctors, but we also need to be the ones to double check, make sure you ask the nurse/doctor, "what are you giving me?" what is that, and why is this test needed?
Example: Bringing up many years ago, and some might relate. My Grandmother always gave her children enemas, for everything. An ear ache?- you got an ***. What in God''s name would you do that for? My mother as a child, could never figure it out, her ear hurt, so why are you shoving something where it doesn''t belong?
There are too many tests being done, and ER visits that shouldn''t be. But the hospitals can not turn anyone away right? We all helped make that law...
We have to be careful what we wish for.
I will be sending a donation, in hopes that it is built right away! God Bless you. My prayers are with the Ferrero family.
The Spinal Cord Research Foundation 4 Children.

[ptmars1]

My partner and I have also started a Non-profit organization, all for CHILDREN with spinal cord disorders. Every comment sheds new light on everything we are doing.If every single nurse, doctor, parent and patient checked everything twice we might not have this problem. Each doctor needs to double check what he writes, and sign it twice, and then every nurse needs to double check him. There should be some sort of computer system set up, for double checking. Some one needs to come up with something, as we are loosing too many people, and children to this huge mistake.
We can blame the nurses and the doctors, but we also need to be the ones to double check, make sure you ask the nurse/doctor, "what are you giving me?" what is that, and why is this test needed?
Example: Bringing up many years ago, and some might relate. My Grandmother always gave her children enemas, for everything. An ear ache?- you got an ***. What in God''s name would you do that for? My mother as a child, could never figure it out, her ear hurt, so why are you shoving something where it doesn''t belong?
There are too many tests being done, and ER visits that shouldn''t be. But the hospitals can not turn anyone away right? We all helped make that law...
We have to be careful what we wish for.
I will be sending a donation, in hopes that it is built right away! God Bless you. My prayers are with the Ferrero family.
The Spinal Cord Research Foundation 4 Children.

Sebastian''s tragedy is about a system that failed at many levels. No one single individual can be entirely blamed for his passing.

There is a reason pediatrics is a specialty in itself. The needs of children are more than just a calculation of body weight versus that of an adult. Doctors and staff in pediatric centers are trained not just in the medical portion of pediatric healthcare. They are also trained in the special techmniques needed to effectively communicate with the family and the patient. Dedicated pediatric facilities are more patient and family friendly, an effort to diminish the stressful effects of an accident or illness.

Hopefully, others will become familiar with Sebastian''s tragedy and will seek to join his parents crusade to improve children healthcare.

[sjw1253]

I have a very rare disease and every time I go to the hospital for the past couple of years has given me pause for concern. Am I going to come out of this alive?

My disease is Lymphangiomatosis (LYMF) and I have lymphatic tumors throughout my organs and in my spine.

A little over a month ago I was taken to the ER with extreme back pain where I could not move. It circled my entire waist and abdomen.

My doctor told me to go to the ER and mentioned his concern of pancreatitis since I have had that in the past.

I mentioned my tumors and no one paid any attention. I was not put on my doctor''s service and was treated for pain and sent home 2 days later still in excrutiating pain. My doctor upped my oxycontin dose which did help.

I went to my spine doctor a couple of weeks ago diagnosed with a compression fracture of my T12 vertebrae - new... I am so lucky I am walking but again have lost faith in the hospital and doctors to address my symtpoms and listen to me...

[puzzler125]

When someone says they are going to the Emergency Room because they have a sore throat, a toothache I ask "WHY?" They usually don''t have a very good answer. The proliferation of E.R. use as a "doctor visit" is what is causing the backlog of cases. Urgent care centers are equipped to treat sore throats, urinary tract infections, minor cuts and injuries, and should be used far more.

[grammawhamma]

As a nurse I have to say some of these medical stories like the "pill swapping article" are not very accurate and are sensationalized by the media. With this story I agree the family has a case.

There are good doctors and there are bad ones. The young doctors might be more knowledgeable about new technology and pharmaceuticals but they are also more gung ho and order every test under the sun and are quick to prescribe a pill for everything and anything. An older doctor in their 60''s or 70''s will be less aggresive with ordering tests and pills for whatever ails you. Some people swear by the new gung ho doctors and some prefer the old home remedy type doctors. It''s up to you to decide what kind of family doctor you want.

[uhyeah1]

I really believe that there are at least 3 problems with our medical system. #1 - people who become doctors don''t care about their patients. #2 - health care costs too much. #3 - the care that physicians are allowed to give to the patient is determined by a bunch of lawyers and businessmen who don''t know jack about medicine. Maybe, just maybe, if insurance companies would just trust the doc and pay the bill, some doctors might be inclined to continue caring about their patients. Why did they get into medicine in the first place? Finally, the people who make these wonderful innovations in medicine should quit being so greedy and make these cures and treatments that they have discovered available to the people that need them. What''s the point of developing something with the guise that you want to help people if you charge so much for it that the ordinary person can''t afford it? Have you really helped anyone other than the rich?

[uhyeah1]

I really believe that there are at least 3 problems with our medical system. #1 - people who become doctors don''t care about their patients. #2 - health care costs too much. #3 - the care that physicians are allowed to give to the patient is determined by a bunch of lawyers and businessmen who don''t know jack about medicine. Maybe, just maybe, if insurance companies would just trust the doc and pay the bill, some doctors might be inclined to continue caring about their patients. Why did they get into medicine in the first place? Finally, the people who make these wonderful innovations in medicine should quit being so greedy and make these cures and treatments that they have discovered available to the people that need them. What''s the point of developing something with the guise that you want to help people if you charge so much for it that the ordinary person can''t afford it? Have you really helped anyone other than the rich?

[incog-nito]

I don''t care how much better or worse other countries are, but the health care system in the U.S. sucks. Four hours or more waiting in an emergency room is actually common everywhere. You practically have to be near death and have an out-of-body experience before anyone sees you, maybe. Drivelphobe is right, the doctors will take 5 minutes max for the exam then writes you up a battery of unnecessary tests. My job involves occasional contact with doctors, and my experience has been that they''re mostly a bunch of arrogant know-it-alls with a god complex. In other countries they''re just professionals. In America they''re businessmen.

[dnamj]

Routine testing is an important tool in catching cancer while it''s still treatable, and that is not a scam.

Look, I think that there are really terrible, structural problems with the American health care system. But avoiding going to the doctor at all costs is not going to help you.

We need a system where doctors practice medicine without the interference of Insurance companies.

[runningralph]

If this had been my child I would have wanted to go after them with a flame thrower. The Ferreros are great people. God have mercy on them.

[taddles-2009]

"The test involved the infusion of the amino acid arginine into his veins. His physician prescribed a dose of 5.75 grams, but the prescription processed by the Shands Medical Plaza''s outpatient pharmacy was 60 grams."


I wouldn''t be surprised if the error were due to misreading the prescription as 57.5 grams. Doctors still routinely fill out prescriptions by hand which leads to errors all the time. Why would they still be hand writing prescriptions in this age of simple technology? Simple arrogance.

[drivelphobe]

A word to the wise. Don''t go to the doctor unless you''re bleeding or ill. Avoid "preventive" testing at all costs. Even annual physicals are a bunch of BS, designed to bring perfectly healthy people to the doctor for no reason other than to generate revenue for the physician.

This poor child, with a legitimate problem, fully aware medical "professionals" on hand, was carelessly treated and a tragedy resulted. Reminds me of Dennis Quaid''s problem in Los Angeles at Cedar Sinai Hospital.

Risks are high even when treatment is necessary. Don''t risk your life and fall for the medical hype that healthy people need to go to the doctor for the "check-up". The doctors will find some reason to give you additional tests under the guise of being "thorough". It''s all about money and they prey on our conditioned pliancy.

Think for yourself. Doctors work for you when you hire them to provide medical services. Don''t let them turn the tables on you.

More proof that medical intervention is the # 1 cause of death in our country.