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Data error led to infant's death; hospital settles with parents

A family will receive $8.25 million from a hospital system in a settlement agreement announced today. The award is compensation for the loss of the couple's baby boy two years ago. The hospital's investigation into what went wrong revealed that a data entry error was the first in a series of mistakes that led to the boy's death.

The baby was born early, about four months premature. He was just 40 days old when he underwent heart surgery; he died soon after the surgery, even though there had been no complications. According to the couple's attorney, the hospital immediately launched an investigation.

The hospital discovered that a member of the pharmaceutical staff had typed in the wrong number when processing an order for IV fluids for the boy. Because the warning systems on the mixing machine were not activated, the staff was unaware of the mistake at that stage. Further compounding the error, the label on the IV bag was incorrect. The baby received IV fluids that contained the wrong concentration of sodium. Then, a lab tech looked at blood test results that showed a high concentration of sodium and assumed the results were incorrect.

After the investigation, the hospital overhauled its IV order and mixing process. The most obvious step was to activate the alert systems on IV compounders. The hospital added steps to the "double checks" staff must complete before releasing medication from the pharmacy.

The changes occurred in the hospital where the accident occurred as well as in all other hospitals in the care system. The promptness of the investigation and the system's implementation of additional safeguards elicited praise from the couple's attorney. He said the hospital had acted quickly to make sure something like this never happened again.

Source: Chicago Tribune, "Parents awarded $8.25 million in infant's death," Cynthia Dizikes, April 5, 2012

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