Deadly Dose: Pharmacy Error Kills Infant

When Alyssa Shinn was born 14 weeks early, she was too tiny and frail to hug.

Her mother, Kathleen Shinn, cradled Alyssa's hands for hours at a time as her firstborn child grew stronger and stronger in neonatal intensive care at Summerlin Hospital in Las Vegas.

Shinn was thrilled when her daughter was born, particularly because she had difficulty conceiving and endured a long and difficult process of in vitro fertilization.

"We were elated when she was born. It was the answer to all our prayers, to everything we wanted," Shinn said.

Her husband, Richard, was equally excited about the birth, calling Alyssa their "miracle baby."

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"She was doing excellent," Richard said of Alyssa right after she was born. "She had just come off the ventilator. She was gaining weight. She was starting to take milk. They just gave her a few drops of milk a day, in a little dropper. And everything was good to go."

'Something Was Not Right'

It seemed that everything was fine until the Shinns left the hospital Nov. 8, 2006 late at night to get some rest after another long day at their daughter's side. Shinn woke up at 3 a.m. and called the hospital to see how Alyssa was doing.

"When I called, they told me that she had some shortness of breath, but that she was OK," Shinn said.

But when the couple returned to the hospital at 9 that morning, the Shinns knew instantly that Alyssa was not OK, that in fact, something was terribly wrong. They saw a group of nurses gathered around Alyssa's isolette, which signaled to Shinn that "something was not right."

Richard noticed a drastic change in their daughter's appearance and demeanor.

"She was very lethargic," Richard said of Alyssa. "She was not moving at all and she was always — she was feisty. What we were used to seeing were her legs and arms going, just a really energetic little girl. And she wasn't moving at all. And the color was leaving her body."

Shinn says she could tell Alyssa was on the brink of death.

"I just knew," she said. "And I just started to cry hysterically, knowing that my daughter Alyssa was going to die."

After confirming that no one else was going to visit Alyssa, physicians turned off the ventilator and the Shinns held their lifeless child for the first time. "We were able to put her in a little dress," said Shinn. "And I got to hold her for the first time."

The Shinns were told that, during the night, Alyssa had received a fatal overdose of zinc from her intravenous nutrition bag, a mistake made in the hospital pharmacy. Pam Goff, the lead pharmacist on duty, was summoned to see her supervisor.

"I just broke down into tears and I started to shake," Goff said. "And I just sobbed uncontrollably. I went back to my desk and started to vomit and cry and shake."

A Fatal Error

The night before, Goff had received a doctor's order for 330 micrograms of zinc, a nutritional supplement to help the baby's metabolism. But when Goff entered the order into the machine that mixes the compound, she entered milligrams — the wrong unit of measurement — on the drop-down menu.

"I put in the 330 and when I went to pick the units … [I] grabbed 330 milligrams per decaliter instead of micrograms per decaliter," said Goff.

This meant that 1,000 times more zinc than had been prescribed was transfused into baby Alyssa.

In July 2007, during an emotional hearing before the Nevada Pharmacy Board, Goff apologized personally and publicly to the Shinns for the first time.

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