In July 2007, during an emotional hearing before the Nevada Pharmacy Board, Goff apologized personally and publicly to the Shinns for the first time.
"Nothing I could ever say would ease your pain. I know that," Goff said in court, turning to face Shinn. "And I want you to know that I'm really sorry."
Shinn hugged Goff and said, "Oh, Pam, I know you're sorry."
The pharmacy board and an investigation by Portfolio magazine have raised troubling questions about the hospital's oversight of its pharmacy. Katherine Eban, the magazine's investigative reporter, says she thought the hospital was run inconsistently (click here to read Portfolio's report).
"I think the Summerlin pharmacy operated like a giant temp agency," Eban said. "Staff came and went. There were six pharmacy directors in six years. One of them was even commuting long distance."
In 2006, Summerlin Hospital had just taken back the operation of its pharmacy from a management company — the third in 10 years — that had hired many of the employees. The night Alyssa received a fatal overdose, the pharmacy was short-staffed, according to Goff.
"It can make it very hectic, and make it very stressful, a stressful situation on everyone that's involved," Goff said of the staffing issues.
The investigation revealed that a series of safeguards simply failed. Two other pharmacists neglected to check Goff's calculation. A safety stop on the mixing machine had not been set, and a technician reading the order had replenished the machine 11 times with zinc; using 48 vials of zinc total to fill the baby's TPN bag. Nurses didn't notice that the nutrition bag was much larger than normal.
In sworn testimony, Goff said that the unusually large size of the nutrition bag should have been noticed.
"That would be completely ridiculous," Goff said of the bag's size. "That bag would be four times the size of her."
The pharmacy board fined Summerlin Hospital pharmacy $10,000, fined Goff $5,000 and placed her on one year's probation. Two other pharmacists were fined $2,500 and given 30-day suspensions.
"That day, an entire system failed, from the very beginning to the very end," said Shinn.
"There were multiple failures," Eban said. "There is the failure of supervision. There is the failure of individual pharmacists. Then there was the failure of the environment. A safe pharmacy has to be a very organized, regimented place with very few distractions."
These types of failures raise serious questions about hospital oversight. In November, the newborn twins of actor Dennis Quaid and his wife were given accidental overdoses of the blood thinner Heparin. The babies survived. And in 2006, six premature infants were the victims of a similar mistake at an Indiana hospital. Three of them died.
"Millions of patients a year get improper medication at hospitals," said Eban. "And it can happen under any corporate or not-for-profit structure. And basically, your best protections against that are stability and management, intensive supervision, a good working environment for those professionals. And when you don't have any of those, then you have a recipe for disaster."
Summerlin Hospital reached a confidential financial settlement with the Shinns. The hospital declined a request for an interview but issued a written statement: