Kristie McNealy, MD

Alyssa Shinn was born 14 weeks early, but she had gradually grown stronger under the watchful eye of the NICU team at Summerlin Hospital in Las Vegas. Then, less than a month into her life, soon after she came off the ventilator and started taking milk, tragedy struck in the form of a medication error. Tiny Alyssa was killed by an accidental overdose when she received a dose of zinc that was 1,000 times higher than what she was prescribed.

Investigation into Alyssa’s tragic death revealed that a series of pharmacy errors in the hospital allowed the overdose to occur. First, the pharmacist filling the prescription accidentally entered the wrong unit of measurement when inputting the prescription, using milligrams instead of micrograms. Next, two other pharmacists on duty failed to check the pharmacist’s calculation, and the safety stop on the medication mixing machine was left unset. The technician who loaded the machine failed to note a problem when they had to refill the zinc in the machine 11 times to prepare one tiny preemie’s IV nutrition bag, and everyone involved, including the nurse who hung the bag failed to notice the fact that the bag was much larger than it should have been.

The problems have been attributed to the fact that the pharmacy was understaffed on the night in question, and there had been a high turn over among pharmacists and other employees for several years leading up to the accident. Fines were issued to the hospital and the three pharmacists involved, but nothing can bring back Alyssa, who was conceived after a long struggle and expensive fertility treatments.

Reading about this story in the news today gave me chills. I don’t know how many times a nurse gave me a dirty look when I glanced at the labels on the meds and IV bags that were hung when Camden was in the NICU. I’ve heard from parents who practically got into fights with nurses before they could convince them that were trying to give their baby an incorrect medication, or a medication prescribed for the baby in the next isolette. I know that nurses and other hospital staff are often overworked and function in high stress environments, but something needs to be done to prevent potentially deadly medication errors like the one that cost Alyssa her life.

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