A 9-month-old girl recovering from an operation was given 10 times the prescribed amount of morphine. The baby went into cardiac arrest and died.
It was all because of a misplaced decimal point. A doctor at Children's Hospital in Washington prescribed 0.5 milligrams of morphine to relieve the infant's pain, but instead she received 5 milligrams.
"We are deeply devastated by this and by the family's grief that we have contributed to and probably caused," said Dr. Peter Holbrook, a hospital spokesman.
Mistakes in the prescription of medicine are common in children's wards, according to a Harvard University study. The study, published in the Journal of the American Medical Association, found medication errors in more than one out of every 18 prescriptions ordered for children.
In reviewing medical records at two Boston hospitals, the researchers discovered repeated examples of the medical staff ordering or administering the wrong drug, or the wrong dose, or at the wrong frequency.
Mistakes More Serious for Children
The error rate — one out of every 18 medications ordered — is similar to what's found among adult patients, but it's more serious for children.
"If you're giving a child he wrong dose of a drug, it's much more likely that you're going to have harm to that child than an adult," says Dr. Joseph Scherger of the University of California at Irvine.
This is especially evident in the cases of the very youngest children, who may weigh only a few pounds. For these patients, a medication error is three times more likely to be potentially harmful.
"Those children are extremely fragile, extremely vulnerable," says Dr. Donald Goldmann of the Children's Hospital in Boston. "The tolerance they have for an error is very, very small."
Researchers say until medication errors can be routinely prevented, parents need to be much more vigilant about the care their children receive in hospitals.
"Know all the drugs your child is getting; know the dosages and schedule of those drugs," says Scherger. "The parent needs to be aware that hospitals are dangerous places."
ABCNEWS' John McKenzie contributed to this report.