The Curious Incident of when Nathan was given the Wrong Medicine at a Major Children’s Hospital

So as the dust has settled today the big question on everyone’s mind has been: So how in the world did they manage to give him a completely incorrect MEDICINE??!!

Here’s what happened.  At 6:30 PM Nathan was moved from PACU to the Pediatric Floor.  The nurse settled him in, gave him meds, and then it was time for shift change.  About 2 hours later, a team of doctors came into the room and then ran out, horror etched on their faces.  After about 20 min’s, an ICU doctor came to speak with us.

“I’m so sorry, but I have to inform you that we accidentally gave your son the wrong MEDICINE.  Not an incorrect dosage or the wrong rate, but the wrong medicine altogether.  Instead of getting an antibiotic, he was getting IV sedation fluids.”

My first question was, “How could that happen?”  His answer was, of course,  I have no idea.

Since then, I have spoken with the Patient Relations Manager at CHLA and the nurse manager to discuss the situation.  Fortunately nothing terribly negative came from the incident for Nathan.  But of course I am horrified that it even happened to being with.  What if it had been a more dangerous medicine?  And when I mentioned this to one of the doctors, their answer was, “This one was bad enough.”

Apparently this is a medicine that should’ve never been out of the ICU environment.  So for this medicine to get into a child on the floor is inexplicable.

I filed a Grievance with the hospital and they’ll be launching an investigation.  Personally, I don’t think they should blame the nurse as there should be fail safes in the system.  They will be looking at the entire process/system, holding a review, and trying to change the structure to protect other kids from having this happen to them.

I figured that if I stayed quiet, no change would come about, and this could happen again.  And next time, perhaps the consequences would’ve been more severe.

Why these things seem to happen to our guy, I don’t know.  Maybe he is an agent for change in this world.  I’m just deeply grateful that he is okay!!



  1. Sheraz says

    Hi Marcela, It is a horrible incident especially when it involve a little kid which was already suffering. I am a father of a son too and if I was in your position I would have sue the hospital for their carelessness and lack of professionalism but I am glad no harm has come to Nathan. He is a sweet child and God bless him with health, happiness and prosperity. Our prayers are always with him.

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