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In memory of Sebastian Ferrero

Please read the story of the Ferreros.

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.
I blogged about this last October, giving the responsible parties my Knucklehead of the Day award. Today the award is more justified than ever, because even more information about what happened to Sebastian and the practices of Shands University of Florida hospital and Shands AGH come to the light of day. Sebastian wasn't the first child to be given an overdose of arginine. Then afterwards when Sebastian was brought to the hospital by his parents, a cat scan was misread. Total incompetence before and afterwards. All the administrators at this hospital did was suspend a nurse and pharmacist. Which I felt was idiotic, Dr. Janet Silverstein Sebastian's doctor failed to do her job and deserves to be fired.

Out of this terrible tragedy, Sebastian's parents have taken the entire legal settlement they won and started a foundation in their son's memory. Their ultimate goal is to open a children's hospital. I don't know if I would have Horst and Luisa Ferrero's strength after losing so much. God bless them and their son Sebastian.

The rest of the AP article is below the fold.

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 worst 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."


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Comments (6)

Tragic errors like this are... (Below threshold)

Tragic errors like this are symptomatic of a dysfunctional system, one that extends way beyond this one hospital.

The Institute of Medicine fixes are not systemic enough, the JCOAH approach is piecemeal.

The best use of money to stop this kind of nonsense is to enforce a systemic change of culture in the practice of medicine. Reform of the malpractice system, institution of real accident/error investigation boards that focus on prevention rather than blame, and training of every person in the medical system to follow practices mandated and accepted in the airline system and nuclear energy systems of our country is the start that is needed.

One such approach is available from this company founded by pilots and flight surgeons -LifeWings:


Unfortunately training like this costs about a thousand dollars per person trained, and a continued commitment from the health system leaders to maintain. But its worth it.

$300,000,000 could train ov... (Below threshold)

$300,000,000 could train over 300,000 health care workers. A lot more than one hospital's worth.

Thank you for helping sprea... (Below threshold)

Thank you for helping spread the word about Sebastian Ferrero and his parents' efforts to improve patient safety for others.

Just exactly what did the P... (Below threshold)

Just exactly what did the Physician do wrong? This is a pharmacy error. Most hospitals do not have "dispensing" liscenses due to government regulations, that believe hospitals and physicians will financially abuse patients.

It is amazing to me to hear the strong resistance to simple reforms (not mandates)by Hospitals and physicians, that could prevent medication errors. Epador is correct, all these discussions usually decend into a blame game of whom is ultimately responsible.

In this case, I would bet the point of lethal error was made by a pharmacy tech.

Imhotep writes-"Ju... (Below threshold)

Imhotep writes-

"Just exactly what did the Physician do wrong? This is a pharmacy error."

Read the original article which was the basis of my Knucklehead award. The link is in the post.

Sebastian's mother asked if the dose was correct before the test was begun, Novak said. It took 30 minutes for the infusion of arginine in solution to drip into his veins. About three-fourths of the way through, Sebastian developed a severe headache.

Headaches can be a side effect of the procedure, Novak said. His father asked that the procedure be stopped and Sebastian was examined by a physician.

The doctor checked Sebastian's chart, but not the bottle of solution. The procedure continued.The doctor didn't check the medicine that was being administered was correct. She killed Sebastian Ferrero through medical incompetence, Janet Silverstein deserves to be fired.

Hi Bill Jempty, You had giv... (Below threshold)

Hi Bill Jempty, You had given reply perfectly about arginine supplements

Russell Reed






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