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This week the Board of Pharmacy of the Florida Department of Health fined pharmacist Edna Irizarry $1000 and required her to attend an 8 hour continuing education course for her role in causing the death of 3 year old Sebastian Ferrero. Horst Ferrero, his father, said “The board choose to apply the minimum penalty $1000 in Sebastian’s case, although the damage inflicted to my son was the maximum possible–his death.”

Sebastian’s father and mother, Luisa Ferrero, choose not to file suit against any of the medical personnel involved in their son’s death and instead have focused their efforts on establishing reliable patient safety protocols to assure that what happened to their son will never happen to another child. The Ferrero’s received a $850,000 settlement from Shands at the University of Florida and have donated all of the money to help establish a full-service, free-standing children’s hospital in Gainesville.

The young child was taken to Shands hospital last October 8 for some routine tests. Based on his weight he should have been prescribed a 5.75 gram dose of arginine. Instead Irizarry, the pharmacist in charge, signed off on a dose 10 times that. Even after the child’s mother questioned the nurse on duty about the dosage, the procedure continued unabated. After the child developed a severe headache Mr. Flerrerro asked the doctor on duty to check out his son but he only looked at his chart and asked the nurse how much medication the boy had received but never examined Sebastian or the bottles of R-Gene that contained the lethal dosage.

The Pharmacy Board decided to levy the light punishment based on Ms. Irizarry’s lack of prior discipline for medical negligence. The Ferroro’s believe that when the mistake cost their son his life, it sends the wrong message to administer minor punishment. Harsher punishment would help spread the word among the medical community, and pharmacists, in particular, that you always need to double check your prescriptions.

This is certainly not the first and it won’t be the last time the medical community fails to recognize that harsh punishment will reinforce the need to protect the public from unnecessary careless and sometimes fatal acts of negligence.

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