Child Dies from Wrong Medication

Dr. Brian Fortuin, chairman of the St. Luke’s Quality Committee at Magic Valley Regional Medical Center, gives a statement Friday pertaining to a child that died after being given the wrong medication at St. Luke’s Magic Valley Regional Medical Center in Twin Falls.

DREW NASH, TIMES-NEWS

TWIN FALLS • A child who died last month at St. Luke’s Magic Valley Medical Center was given an adult dose of a saline solution infused with potassium phosphate, the hospital said Friday.

Seven-month-old August Dean Elliott came to the emergency room about 11 p.m. Sept. 22 with heart problems and was pronounced dead a few hours later.

The child’s death triggered an internal investigation, which the hospital detailed in a statement released to the Times-News on Friday.

St. Luke’s said the child’s medication was mixed up with a similar medication prepared for an adult also being treated that night in the emergency room.

“One of our nurses prepared the adult patient’s medication solution at the nurse’s station,” the hospital said in the statement. “Sometime later, another nurse mistook that prepared bag as the one to be used for the child, took it into August’s room, and administered it. Approximately 10 minutes later, August went into cardiac arrest and we began resuscitation efforts. Thirteen minutes into that effort, another nurse read the label on the bag and realized August was receiving the wrong medication. Sadly, despite efforts to revive him, August died shortly after 4 a.m. on Wednesday, September 23.”

The adult dosage was in a bag that looked similar to the bag prepared for the baby, but they were labeled differently, St. Luke’s said.

The hospital announced August’s death at a press conference Sept. 25. Family attorney Jarom Whitehead confirmed the identity of the boy Monday and said the family cooperated with the hospital in its internal investigation.

Department leaders at St. Luke’s Magic Valley Medical Center were updated on medication protocol Thursday at a daily “patient huddle,” hospital spokeswoman Michelle Bartlome said. More training and adjustments are likely to follow.

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“We missed at least one part of the standard procedure for administering medication,” the hospital said in the statement. “We deeply regret that mistake, and we are actively tightening our processes to minimize the chances of human error in the future.”

The hospital’s investigation report will be submitted to the the nation’s top hospital accreditation board. St. Luke’s will also submit the completed report to the county coroner. It has shared the report’s findings with the baby’s family on Friday.

A separate investigation by Twin Falls police is also underway at the request of the Twin Falls County Prosecutor’s Office. Twin Falls County Prosecuting Attorney Grant Loebs said investigators are still gathering information.

In its statement, St. Luke’s again expressed remorse for the mistake. It declined to field follow-up questions after issuing the statement.

“All of us at St. Luke’s are devastated by this mistake that caused August Elliot’s death,” the hospital said. “While we have expressed our deepest and most heartfelt apologies to the Elliot family, we know words will never be enough to ease their pain. We continue to offer any support we can to this family.”

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