A 2-year-old cancer patient died, apparently from excessive levels of potassium in an intravenous feeding solution, Johns Hopkins Hospital said Friday.
The Johns Hopkins Children’s Center said human error was the most likely explanation for the Dec. 4 death of Brianna Cohen. It said it accepted full responsibility. The death has prompted a Johns Hopkins home care division to end hand-mixing of the preparations, a hospital statement said.
An autopsy wasn’t performed on the child at the family’s request, but tests following the child’s death showed “excessively high levels of potassium” in the Total Parenteral Nutrition solution, which contains proteins, fats, vitamins, minerals and other nutrients, the statement said.
The amount of potassium was four to five times higher than called for, the Children’s Center said.
“Although our analysis is incomplete, and we are as yet unable to recreate the precise series of events that occurred, Hopkins fully accepts that the most likely explanation for this tragic event is that human error occurred in the manual formulation of the solutions,” the statement said.
Miscommunication between the hospital and one of its pharmacies may have been a contributing factor, the statement said.
In response to the death, the hospital said, the preparation of all Home Care TNP solutions for children and adults will be done by fully automated systems now used for Hopkins inpatients.
New solutions were also distributed to home-care pediatric and adult patients and solutions delivered before Dec. 11 have been replaced.
In addition to accepting full responsibility, Hopkins said it is fully cooperating with the family and has notified regulatory agencies.
In 2001, the Children’s Center launched a patient safety initiative after the death of an 18-month-old. The toddler died after the staff failed to treat her for severe dehydration.