A Case of Medication Error: Conversion

Factors in Clinical Calculations
by
Brahmadeo Dewprashad
Department of Science
Borough of Manhattan Community College, The City University of New York
ME Rules Death Of Brooklyn 6-Month-Old ‘Accident’ Resulting From Antibiotic Overdose
Brookdale Hospital Investigating How 17-Pound Baby Got An Adult Dosage
October 26, 2011 11:57 PM
NEW YORK (CBSNewYork) — A Brooklyn family is dealing with absolute devastation after their only child died following
a fatal mistake. Th eir baby boy was taken to the hospital with just a fever and was given what turned out to be a deadly dose
of medication.
Earlier Wednesday afternoon, the New York City Medical Examiner ruled the death of 6-month-old Amaan Ahmmad an
accident. Th e ME said the death was the result of complications following administration of an adult dose of the antibiotic
azithromycin, which is commercially known as Zithromax.
Instead of looking forward to a lifetime of birthdays, the family is now making funeral arrangements for their child. Ummay
Sultana and Amain Ahmmad said their son became ill last Friday, so they took him to Brookdale, where he was born.
“He catch cold and we took him to the emergency,” Sultana said.
Hospital records showed baby Amaan was brought to the ER “alert and responsive” and with the exception of a fever, which
was reportedly around 100, the nursing staff did not list any other visible symptoms.
But an examination led to a diagnosis of clinical pneumonia. Amaan was transferred to the pediatric unit and given a dose of
the azithromycin through an IV drip in his right arm.
According to the nursing notes, at least 36 minutes passed before the hospital staff realized something was wrong.
CBS 2’s Jay Dow spoke with the parents Wednesday and asked the boy’s father who he blames for his son’s death.
“Hospital management, doctor, nurse—of emergency,” he replied.
“I’m like ‘look, look my baby’s dying! My baby’s dying!’ and then nurse came over and said ‘no, you’re baby’s pretty good. He’s
sleeping,’” Sultana told CBS 2’s Sean Hennessey.
A copy of the hospital’s discharge summary states the child was given “Azithromycin (500mg), in error” — which led to
“cardiac shock.”
Family pediatrician Dr. Suzanne Loiselle said that dosage is more typical for an adult and not a 17-pound baby like Amaan.
“Nobody can feel worse for the family than the doctors and nurses that were involved in this child’s care,” Loiselle said. “About
80 milligrams would be appropriate for a child roughly in his weight class.”
Less than 24 hours after the overdose, Ummay and Amain were told their son was brain dead. Amaan was taken off a respirator
on Monday.
“Th ey told us there is no hope because his head is totally collapsed,” his father told Hennessey.
Brookdale Hospital would not answer questions from 1010 WINS or CBS 2, saying only: “We are investigating the circum
stances of this tragic incident and express our condolences to the Ahmmad family.”
“I never think like that he pass away forever,” Sultana said. “I thought he’s gonna come back.”
T
h e two fi rst-time parents said they are both devastated and outraged over a fatal medical mistake that cut short their baby’s
life just as it was getting started.
—Printed with permission of CBS Local
“A Case of Medication Error” by Brahmadeo Dewprashad
Page 1
Pre-Case Questions (40 points)
NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
1. Sultana indicated that the baby “catch cold and we took him to the emergency.” She was referring to what is
known as the “common cold.” What causes the “common cold”? What are its symptoms? How is it usually
treated? Is the underlying cause of the illness treated or are only its symptoms treated? (3 points)
Reference: http://www.niaid.nih.gov/topics/commoncold/pages/default.aspx
2. Th e “common cold” and infl uenza (fl u) are diff erent. What causes infl uenza? What are its symptoms and how is
it generally treated? (3 points)
Reference: http://www.niaid.nih.gov/topics/Flu/understandingFlu/Pages/overview.aspx
3. What is pneumonia? What causes it? What is its relationship to infl uenza and the common cold? (3 points)
Reference: http://www.niaid.nih.gov/topics/pneumonia/Pages/Default.aspx
4. Pneumonia is usually treated with antibiotics. What is an antibiotic? (3 points)
Reference: http://www.nlm.nih.gov/medlineplus/antibiotics.html

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