Dear staff and faculty members,

Every day clinicians and support staff at Seattle Children's do their best to provide the highest
levels of quality and safety to our patients and families. Our use of continuous performance
improvement supports this commitment and the benefits of these improvements are evident
throughout the organization. However, despite the work we do to improve our medication and
safety systems - errors are still possible. I want you to be aware of a medication error that
resulted in the death of one of our patients and what we are doing to reduce the risk of harm to
future patients.
A nurse in the ICU administered ten times the intended dose of a medication, calcium chloride.
The infant was profoundly fragile and succumbed to complications from the overdose several
days later. This was a catastrophic outcome for the patient and family, and caused serious
distress for staff members as well. We have offered our heartfelt apologies to the family of the
patient and will do all that we can to help them in this time of grief. Of course, we will also
support our staff members during this difficult time.
Perhaps the best tribute we can pay to this family is by doing everything we can to prevent
future medical errors in our system. An important way we can make medicine safer is if we
admit that mistakes occur and openly investigate them. We must learn from these events and
work together to evaluate our processes and to error-proof our care processes. It is important to
me that all staff and faculty feel it is safe to report when mistakes are made, and that everyone
is confident that we recognize the difference between an honest mistake and reckless behavior.
Immediately following the incident, we reviewed the clinical record and began a detailed root-
cause analysis to determine why our usual safety checks did not prevent this tragic error. While
our investigation is underway, we have taken the following actions:
Now, only pharmacists and anesthesiologists can draw-up calcium chloride in non-
emergent situations. However, the drug remains on code carts, which can be accessed
by medical or nursing staff if a patient needs the dose emergently.
We have reported this to the Department of Health as a sentinel event and begun the
required review.
We are looking for additional ways to eliminate further risk to current and future patients.
The error highlights the narrow margins of safety within which we do our daily work. Most
importantly, it represents a sobering reminder of the importance of following standards of
practice and established policies and procedures in every case.
I wanted to make you aware of the incident and I know you join us in our sadness for the
patient, their family, the clinician involved and all staff who each day do their best to protect and
heal our patients.
I encourage you to be vigilant about the ways we can improve patient safety and send any
comments or suggestions to our Associate Medical Director for Patient Safety or Director of
Patient Safety.
To respect the privacy of this family during their time of grief we will not be releasing additional
details without the family's permission.

Sincerely,
Dr. Tom Hansen
CEO
Seattle Children's