State health authorities investigating another death at Children's hospital

The state Department of Health is investigating the death of another child at Seattle Children's hospital — a newborn who died two days before an 8-month-old girl died Sept. 19 of a medication overdose.

At a news briefing Thursday evening, Dr. David Fisher, Children's medical director, said the critically ill newborn was being transported from another hospital to Children's in Children's neonatal ambulance on Sept. 17.

Fisher said a staff member in the ambulance gave the newborn medication that's often administered in that same dose to infants who are difficult to ventilate or have unstable airways, but that it was given without orders from a licensed prescriber.

That was a violation of hospital policy, Fisher said, but whether it caused the baby's death is not yet known. "I want to stress that it is quite possible that these medications had nothing to do with the death of this infant," he said. He did not disclose the baby's name, age or gender.

Tim Church, spokesman for the state Department of Health, said state investigators were at the hospital Thursday looking into the Sept. 19 death when Children's officials told them about the Sept. 17 death.

At the news conference, the hospital also disclosed a recent nonfatal case involving an adult, saying the adult had arrived at the hospital's ER with life-threatening respiratory distress last Sunday, with no time to get to another hospital.

Fisher said staff gave the adult medication in a vein rather than a muscle. The patient was stabilized and transferred to a hospital for adults, Fisher said, and has since recovered.

On Tuesday, the hospital announced to its staff the death of 8-month-old Kaia Zautner, who died Sept. 19, several days after a nurse gave her 10 times the proper dose of a medication, calcium chloride.

"Our mission is to provide excellent care for children," Fisher said at the news conference. "We failed in our effort to provide safe care, and we are devastated."

Still, Children's remains a safe facility, he said, where more than 1,000 children a day are seen and more than a million medications per year are administered. He said the hospital has been reviewing its safety policies and systems and that more than 1,000 staffers have attended mandatory sessions this week.

"There is a lot of anguish and angst" among staff, he said.

For one day, Fisher said, at a date not yet set, the hospital will suspend all nonemergency operations, including outpatient clinics and elective surgeries, to review patient-safety practices in an attempt to find areas of weakness.

"We treat children with the most complex medical conditions in the Northwest," Fisher said. "We will commit whatever financial resources it takes to provide the safest possible patient care."

Earlier Thursday, Church said the hospital had not reported an "adverse event" involving the newborn who died in the ambulance.

Under state laws, hospitals must report events listed as preventable medical errors — including medication errors associated with serious disability or death — within 48 hours of learning about them.

Fisher said the newborn's cause of death has not yet been determined.

Children's staff learned about Kaia Zautner's death in a notice from hospital CEO Tom Hansen. In it, he said the hospital had offered heartfelt apologies to the family.

"This was a catastrophic outcome for the patient and the family, and caused serious distress for staff members as well," Hansen said.

After the overdose, the hospital reviewed the clinical record and began a detailed analysis of why the usual safety checks had not prevented it, Hansen told the staff.

"Perhaps the best tribute we can pay to this family is by doing everything we can to prevent future medical errors in our system," he wrote. "An important way we can make medicine safer is if we admit that mistakes occur and openly investigate them. We must learn from these events and work together to evaluate our processes and to error-proof our care processes."

Thursday, Fisher declined to say whether any employees involved in the incidents had been disciplined or removed. "Humans make errors," he said.

Church said investigators from the division that licenses hospitals are looking at "systems, policies and procedures" at Children's to determine whether the incidents involved employee error or a fault in a system that's supposed to catch such mistakes.

In 2009, the 250-bed hospital performed 13,331 surgical, cardiac, kidney and transplant procedures, according to documents Children's filed with the state Department of Health.

As of this June, it had reported one serious medication error since 2006, when the state began collecting reports of adverse events.

Carol Ostrom: 206-464-2249 or costrom@seattletimes.com