Infant dies of accidental overdose at Children's Hospital

Infant dies of accidental overdose at Children's Hospital
Kaia Zautner is seen in this family photo.
SEATTLE -- A baby girl at Children's Hospital died after a nurse mistakenly administered a lethal dose of medication, hospital officials said.

Eight-month-old Kaia M. Zautner of Puyallup died 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 intended dose of a medication, calcium chloride."

"The infant was profoundly fragile and succumbed to complications from the overdose several days later," the letter said.

A hospital spokesperson refused to provide any additional details about the case, but family members described the harrowing incident on a blog dedicated to tracking the infant's condition.

"What happened is this- One of Kaia's nurses accidently miscalculated the dosage 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 high runs of heart rate and also her oxygen saturations went way down.

"What this means is that there wasn't suffcient 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 exactly 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 responsive." Doctors determined her heart was malfunctioning and hooked her up to a machine that helps regulate the heart's functions. Blog posts indicate the infant has been struggling since.

It is not known whether the nurse involved will face any disciplinary action.

Hansen said the hospital has notified the state Department of Health, and has launched an investigation to determine why its safeguards failed to prevent to death.

"This was a catastrophic outcome for the patient and family, and caused serious 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 prevent future medical errors in our system."

In the wake of the incident, Hansen said the hospital has changed its policy to only allow pharmacists and anesthesiologists to access calcium chloride in non-emergency situations. He added the investigation is ongoing, and officials are looking for additional ways to cut risk to patients.

Last year, an autistic teenage boy died after undergoing routine oral surgery at the hospital.

Michael Blankenship couldn't speak or take oral medications. As a result, doctors prescribed a patch containing fentanyl, a powerful painkiller, following his March 2009 surgery. The patch, which was placed on his back, is typically used on cancer patients or people with a narcotics tolerance.

"Clearly the dose was too much for this patient," Dr. David Fisher, the hospital's medical director said last year.

The boy's mother, Tammy Blankenship, filed a claim against the hospital and two dentists for more than a million dollars. The two sides settled for an undisclosed amount.

"I can't bring my child back. I can't reverse the decision made to prescribe a drug that killed him," she said.

In the Blankenship case, the hospital did not discipline the doctor or the medical team involved, saying no one intended to harm the boy and no process had been in place to determine whether fentanyl was appropriate for specific patients.