Parents want tougher sanction

While relieved that three pharmacists and a pharmacy technician admitted to errors that caused the death of their infant daughter last year, Kathleen and Richard Shinn don't believe $2,500 fines, 30-day suspensions and extra training are adequate punishment for their loss.

The Shinns appreciated Wednesday's Nevada State Pharmacy Board hearing exploring the series of errors that led to daughter Alyssa receiving a lethal overdose of Zinc on Nov. 9, while in Summerlin Hospital's neonatal intensive care unit. The infant, born premature on Oct. 19, was given a dose of zinc 1,000 times larger than her physician had ordered to be added to the intravenous solution that was her only source of nutrition.

The Shinns said Friday that pharmacists Pamela Goff, Nazanin Rezvan and Jackson Yu should not be allowed to continue filling prescriptions.

To receive closure on the death of the child the couple conceived through in vitro fertilization, the Shinns also said they need Summerlin Hospital to be held accountable.

"They took from us the very thing we've always wanted,'' Richard Shinn said Friday as he sat at the bar in the Summerlin home he used to share with Kathleen.

The couple divorced earlier this year.

On Wednesday, the Pharmacy Board fined Summerlin Hospital's pharmacy $10,000, the maximum allowed, plus the cost of the investigation into the incident. For failing to verify the accuracy of the order, Goff, Rezvan and Yu were fined $2,500 each, had their licenses suspended for 30 days and were ordered to attend additional training.

Asia Cornelius, the pharmacy technician who filled the order, putting the zinc in Alyssa's Total Parenteral Nutrition IV bag, received no punishment.

The Shinns have not filed a lawsuit against Summerlin Hospital. They said they don't know whether they will. They plan to take some time to make that decision.

During Wednesday's hearing, Summerlin Hospital representatives said they had implemented new policies and procedures to prevent such errors.

But the Shinns said the changes are incomplete and don't ensure that patients are safe.

Gretta Worthington, the former director of pharmacy at Summerlin Hospital, said the hospital has made numerous changes to prevent medication errors and create a safer environment for patients. Those changes include a requirement that pharmacists and pharmacy technicians undergo annual Total Parenteral Nutrition training.

Outside of the hearing, Summerlin Hospital officials have refused to answer questions this week because of the possibility of litigation.

"Summerlin generated this huge Bible of policies and procedures," said Kathleen Shinn, a registered nurse at Southern Hills Hospital. But the training "is given during orientation. Only new employees are oriented, not everyone else."

The IV bag prepared for Alyssa was to contain 330 micrograms of zinc, but because of an error by Goff, the order was entered as 330 milligrams of zinc.

Goff's error was missed by Rezvan, who was supposed to check it for accuracy. It was also missed by Cornelius, who injected the zinc into the IV bag from more than 40 vials. The error also got past Yu and several neonatal intensive care unit nurses who had been at Alyssa's bedside.

"I sit on a medical safety team. I know what it takes,'' said Kathleen Shinn. "No one was steering the boat at this hospital the night Alyssa died. And from what I heard on Wednesday, there might not be anyone doing it now.''

Worthington, who resigned in May, was the seventh director of pharmacy at the hospital in six years, the Shinns said.

The Pharmacy Board noted the high turnover in pharmacy directors during the hearing.

The Shinns were also concerned the Pharmacy Board did not punish Cornelius.

Cornelius admitted Wednesday that she had limited training on the machine used to fill Alyssa's pharmacy order.

Christopher Henderson, the Shinns' attorney, said allowing Cornelius to operate the compounding machine was like "taking a pilot with just 40 hours of flying a Cessna and putting them in the cockpit of a 747 and just saying, 'Go for it.' "

Board members said they didn't have the authority to revoke Cornelius' license because she isn't directly licensed by the board.

But the Shinns said it's time for the state to look at who oversees pharmacy technicians' training and actions. "That's terrifying that she's still able to fill prescriptions,'' Kathleen Shinn said.

The Shinns also questioned Goff's competence. But Kathleen Shinn showed sympathy for her during Wednesday's hearing.

When Goff turned to the Shinns and apologized between sobs, Kathleen Shinn stood and walked to the table where Goff was sitting and the two embraced for at least a minute.

"I know what's happened to Pam (Goff). When people recognize they've made a mistake and are willing to admit to them and tell their side, it gives resolution and it helps with the healing,'' Kathleen Shinn said Friday, dabbing tears from her bloodshot eyes. "I know there was no malicious intent. ... With my own experience giving chemotherapy agents and cardiovascular medication to patients, those medications can kill you if you calculate them wrong. I know that having to live up to that responsibility is hard.''

Richard Shinn said there are a few questions they would still like answered, among them exactly when his daughter died.

The Shinns were told Alyssa died at 4:20 p.m. But based on their medical knowledge and the actions of hospital administrative staff when they arrived at the hospital at 9 a.m. on Nov. 9, they believe their daughter died much earlier.

"At 10:30 a.m., when we returned to her room, there was no ventricular activity. There was no wave on the arterial lines" used to monitor blood pressure, said Kathleen Shinn. "I know she was dead."

Kathleen Shinn said she plans to remain vocal on behalf of Alyssa and other patients at Summerlin Hospital and other medical facilities throughout the Las Vegas Valley. But, she said, she also believes Alyssa would want her to forgive those health care workers whose errors led to the infant's death.

"I've been in therapy ever since Alyssa died,'' she said. "I've been working on how to resolve my feelings but, at the same time, I've felt really guilty, like I wasn't being loyal to Alyssa. But I know she would have wanted me to forgive."