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http://www.nytimes.com/2002/05/25/nyregion/25BABY.html

State Finds That a Series of Health Care Violations Led to an Infant's Death

By BRUCE LAMBERT

ew York State investigators have concluded that the tenfold medication overdose that killed a 6-day-old boy at a Long Island hospital stemmed from a series of serious health care violations.

Officials at the State Health Department are now considering what penalties to impose on Stony Brook University Hospital, where the baby, Gianni Vargas, died in February.

Immediately after the death, the baby's parents said that hospital officials had acknowledged the overdose and had placed the blame on a missing decimal point in the infant's prescription for potassium chloride.

But the state's follow-up report details numerous violations of laws and procedures and cites failures by people ranging from the workers who treated the baby to the hospital's top administrators. If procedures had been followed, health officials said, the overdose could have been prevented at several different points.

Responding to the report, the hospital said yesterday that it was taking a variety of corrective steps, as well as making improvements already planned before the death, that should meet the state's requirements and concerns.

"We knew from the beginning it was more than a missing decimal point," said David J. Raimondo, the lawyer for the parents, Ana and Giovanni Vargas of Brentwood. They have filed a notice of claim against the hospital for malpractice and negligence.

Mr. Raimondo praised the state's findings, which were first reported yesterday in Newsday, as proving "a complete failure from the C.E.O. down to the nurse practitioner." He added: "There was not just one mistake but a complete collapse, from top to bottom."

Health officials had previously reprimanded Stony Brook after an infant survived a tenfold overdose of morphine in 1995. The history of overdosing will figure into the penalties against Stony Brook, said the Health Department's spokesman, Robert Kenny.

Among the many problems cited in the Vargas case was that the nurse practitioner wrote the prescription without notifying a doctor, violating Stony Brook policy, Mr. Kenny said. The prescription was then filled by a poorly supervised pharmacy technician who was not authorized by state law to fill prescriptions. Eventually a nurse gave the medicine to the baby, but again hospital policy was violated, and no doctor was notified.

The hospital administration issued a statement saying, "We have taken a number of significant steps to reinforce patient safety." The remedial actions include investing $25 million in technology with a computer system that flags unusual medicine dosages. The hospital said that it was also recruiting new pharmacy managers, creating a patient safety committee, giving the staff more training, adopting new procedures for high-risk medications and hiring consultants "to ensure the highest levels of quality."

Mr. and Mrs. Vargas would not comment, their lawyer said. "The parents are grieving," he said. "They're coping."

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