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Saturday, 15/11/2025 | 12:24 GMT+7

Doctor's comma error in prescription leads to boy's overdose death

A two-year-old boy was prescribed 1,5 mmol of potassium phosphate, but a doctor removed the decimal point when entering the prescription into the computer, causing the patient to receive ten times the dosage and die.

On 6/11, the family of victim De'Markus filed a lawsuit with the Alachua County Court in Florida, accusing UF Health Shands Children's Hospital (part of the University of Florida) of "medical negligence" leading to the boy's wrongful death.

According to the complaint, the boy's parents brought him to another hospital for treatment starting 1/3/2024 due to persistent crying, diarrhea, and loss of appetite. De'Markus was diagnosed with rhinovirus and enterovirus, common causes of respiratory illnesses like the common cold.

De'Markus was also found to have low potassium levels, and the emergency department began intravenous treatment, transferring him to UF Health Shands the next day for better care.

Upon arrival at UF Health Shands, doctors discovered De'Markus's potassium levels were "dangerously low" and initiated treatment.

UF Health Shands Children's Hospital. Photo: NYPost

During his treatment there, on the first day, doctors prescribed oral potassium phosphate at a dosage of 1,5 mmol twice a day. However, on the second day, a doctor incorrectly entered the oral potassium phosphate prescription for De'Markus with a dosage ten times higher than what was prescribed the previous day.

"The doctor erred in prescribing oral potassium phosphate at ten times the previous dosage, deleting a crucial decimal point in the 1,5 mmol dose, making the prescription 15 mmol twice a day," the complaint states. This level is considered extremely high for a two-year-old.

De'Markus's family stated that the initial potassium phosphate prescription was calculated based on his size, weight, and "laboratory results and electrolyte needs" from the first day of admission. Medical staff reportedly failed to detect and correct this error, and complications soon arose.

The complaint alleges that pharmacists and supervising physicians either failed to detect the error or deliberately ignored it, even though the hospital's computer system flagged a "red flag" for the excessive dosage.

The lack of appropriate emergency equipment in the pediatric department and the absence of blood electrolyte monitoring equipment led De'Markus to develop hyperkalemia and suffer cardiac arrest. The hospital also failed to recognize the cardiac arrest and waited over 20 minutes before initiating intubation, according to the complaint.

After suffering severe hypoxic injury, De'Markus underwent two weeks of treatment, requiring mechanical ventilation in the pediatric intensive care unit, and passed away on 18/3/2024.

"This tragic case highlights serious concerns about patient safety, pediatric care protocols, and the supervision of the most vulnerable children with special needs," the lawsuit states. The family is seeking at least USD 50,000 in joint compensation from the defendants, including the hospital and 14 doctors, nurses, and pharmacists directly involved in the boy's care during his 18-day hospital stay.

The defendants have not responded to the lawsuit, citing "patient privacy."

Hai Thu (According to Law and Crime, Fox 10, NYPost)

By VnExpress: https://vnexpress.net/bac-si-nham-dau-phay-khi-ke-don-khien-be-trai-tu-vong-vi-qua-lieu-4964301.html
Tags: prescription doctor medical negligence US hospital lawsuit patient medication order

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