Nursing board will get report on girl’s zinc overdose death

The state's nursing board will receive a report from the pharmacy board regarding the circumstances surrounding the Nov. 9 death of Alyssa Shinn inside Summerlin Hospital Medical Center's neonatal intensive care unit.

It's unclear, though, whether the Nevada State Nursing Board will use this information to determine if nurses under its jurisdiction violated any professional practices when they received Alyssa's food-containing IV bag from the hospital's pharmacy and failed to check the zinc content.

According to testimony during a Nevada State Board of Pharmacy hearing last week, nurses failed to notice that Alyssa's food-containing IV bag was bulky and probably larger than her body. The bag contained 1,000 times the zinc she had been prescribed.

Alyssa died as a result of prematurity and a zinc overdose.

Louis Ling, attorney for the pharmacy board, said the agency will submit a report to the nursing board about its findings and decision to discipline Summerlin Hospital's pharmacy and three pharmacists.

"We will be getting this over there,'' Ling said Monday morning.

According to the hospital, members of the nursing staff at Summerlin Hospital, who have not been publicly identified, were disciplined and allowed to return to work with instruction and counseling.

The nursing board is a state agency that licenses, regulates and disciplines registered nurses, licensed practical nurses, certified nursing assistants, advanced practitioners of nursing and certified registered nurse anesthetists.

Cindy Kimball, a spokeswoman for the nursing board, said that whenever the state agency receives written complaints concerning individuals holding licenses or who are registered with the Nursing Board, those cases are evaluated. Evaluations includes looking for possible violations of the Nevada Nurse Practice Act.

If violations are found, a complete investigation is initiated, she said.

Written complaints can come from the general public, health agencies, medical care facilities and providers, nurses themselves or the coroner's office.

Kimball would neither confirm nor deny Monday whether the state had already received a complaint regarding nurses involved in the incident.

"The only time information would be available is when the board is hearing the case or if a settlement has been reached,'' she said.

Kimball said disciplinary actions, which range from public reprimands to fines, suspensions, probation and or revocation of license or certification, take place during the Nursing Board's scheduled meetings. Meetings are held every two months and the next one is scheduled for September.

"If we got a complaint tomorrow, that would not be enough time for an investigation to be completed,'' she said.

Last week, the pharmacy board fined Summerlin Hospital's pharmacy $10,000 and pharmacists Pamela Goff, Nazanin Rezvan and Jackson Yu $2,500 each for violating state law in relation to mistakes they made while preparing Alyssa's total parenteral nutrition, food that is administered intravenously.

Asia Cornelius, a pharmacy technician, was not punished even though she was the one who physically injected the IV bag with the large amounts of zinc.

During her testimony, Cornelius said she felt something may have been wrong but didn't reveal those feelings until more than three hours after Alyssa had received the IV.

Ling said pharmacy technicians aren't typically disciplined even though they are licensed through the agency.

"The board's policy is that the pharmacist is responsible for pharmacy technicians,'' he said. "The law is that everything the technician does should be checked by the pharmacist.

"The failure was on part of the hospital," he said, because Yu was not required to verify the ingredient levels in the IV solution.

"The hospital has changed that policy," Ling said.