A baby girl at Children's Hospital died after a nurse incorrectly administered a lethal dose of medication, hospital officials said. Eight-month-old Kaia M. Zautner of Puyallup passed away on Sept. 19 after suffering a brain hemorrhage, according to family members. Hospital CEO Dr. Tom Hansen outlined the incident in a letter sent to staff members last week.Hansen said a nurse in the intensive care unit recently "administered 10 times the planned dose of a medication, calcium chloride." "The infant was deeply fragile and succumbed to complications from the overdose several days later," the letter said.
A hospital spokesperson refused to offer any additional details about the case, but family members described the harrowing incident on a blog dedicated to tracking the infant's condition.
"What took place is this- One of Kaia's nurses accidently miscalculated the amount of calcium chloride that Kaia was to receive," a post on the blog said. "This was in the morning. Throughout the morning and into the afternoon Kaia started showing signs of elevated runs of heart rate and also her oxygen saturations went way down.
"What this means is that there wasn't adequate oxygen in her blood and the reason this happened is because the calcium chloride caused Kaia's heart to basically go into cardiac arrest and the right ventricular shut down so she wasn't able to transfer very much, if any, blood to her lungs. We aren't sure precisely how long her internal organs and brain were not receiving good oxygenated blood supply, but it was at least an hour."
According to the blog, the baby girl was born "a little blue, not breathing very well and not very receptive." Doctors determined her heart was malfunctioning and hooked her up to a machine that helps control the heart's functions. Blog posts indicate the infant has been harassed since.
It is not known whether the nurse involved will face any penal action. Hansen said the hospital has notified the state Department of Health, and has launched an investigation to conclude why its safeguards failed to prevent to death.
"This was a catastrophic outcome for the patient and family, and caused severe distress for staff members as well," Hansen wrote. "Perhaps the best tribute we can pay to this family is by doing everything we can to stop future medical errors in our system."
In the wake of the incident, Hansen said the hospital has distorted its policy to only allow pharmacists and anesthesiologists to use calcium chloride in non-emergency situations. He added the investigation is enduring, and officials are looking for additional ways to cut risk to patients.
