Reason For Infant Death Released by St. Luke’s
TWIN FALLS, Id. ( KMVT / KSVT) St. Luke’s in Twin Falls has released further information following the death of a child in September.
The hospital issued the following statement.
On Tuesday night, September 22 at approximately 11 p.m., we treated a young child with cardiac issues at St. Luke's Magic Valley. Seven-month old August Elliot’s attending physician in the Emergency Department examined him and determined one of the appropriate treatments for his condition was saline fluid. Another of the patients in the Emergency Department that night had been prescribed a saline solution infused with Potassium Phosphate; that bag was similar in size, shape and color to the normal saline the child was prescribed to receive. The only difference was, it was labeled for the adult patient as containing Potassium Phosphate.
One of our nurses prepared the adult patient’s medication solution at the nurse’s station. Sometime later, another nurse mistook that prepared bag as the one to be used for the child, took it into August’s room, and administered it. Approximately 10 minutes later, August went into cardiac arrest and we began resuscitation efforts. Thirteen minutes into that effort, another nurse read the label on the bag and realized August was receiving the wrong medication. Sadly, despite efforts to revive him, August died shortly after 4 a.m. on Wednesday, September 23.
We missed at least one part of the standard procedure for administering medication. We deeply regret that mistake, and we are actively tightening our processes to minimize the chances of human error in the future.
Today, we provided August’s family with this information, which we determined from our investigation into this tragic event. We will now share those results with appropriate authorities. We have also taken steps across St. Luke’s Health System to ensure this mistake will not be repeated.
All of us at St. Luke’s are devastated by this mistake that caused August Elliot’s death. While we have expressed our deepest and most heartfelt apologies to the Elliot family, we know words will never be enough to ease their pain. We continue to offer any support we can to this family.