Canada 2 accidental child deaths, 3 weeks apart prompt changes at Montreal's Sainte-Justine Hospital

15:47  17 april  2018
15:47  17 april  2018 Source:   cbc.ca

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Because accidents are the leading cause of death in children 18 and younger. We are proud to report that this initiative has resonated with over 100 professionals and prompted them to lend their support to the scientific minds of tomorrow at Sainte - Justine .

In fact, one in three children is at risk of developing a heart problem, while accidents are the leading cause of death in children under the age of 18. In the area of acute critical care, your donations were used to improve the CHU Sainte - Justine ’ s trauma program and allowed us to bring in a greater

a close up of text on a black background: Coroner Jacques Ramsay's report is clear that both deaths were accidental, and the hospital says it has already taken measures to avoid similar instances from happening again.© Radio-Canada Coroner Jacques Ramsay's report is clear that both deaths were accidental, and the hospital says it has already taken measures to avoid similar instances from happening again.

The deaths of two young children at Montreal's Sainte-Justine Hospital that happened within weeks of each other have led the hospital to take measures to reduce the risk of death — and to pass those insights on to other health institutions.

In his reports, coroner Jacques Ramsay makes it clear both deaths were accidental, and the hospital says it has taken steps since they took place to avoid similar instances from happening again.

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As a result, Kurling for Kids has “swept in” more than $ 2 .5 million for Montreal ’ s two pediatric facilities in order to purchase high-tech medical equipment. In 2016, thanks to these efforts, Sainte - Justine became the first children ’s hospital in Canada to acquire an

"It can't be repeated enough: to err is human," Ramsay said in an interview.

The coroner dismissed any theory that the deaths were the results of malicious actions. Both were the result of higher dose of potassium than required.

Kaylynn Mianscum-Kelly, who was diagnosed with Down syndrome, was barely three months old when she died on Nov. 18, 2016.

A nurse put 10 times more potassium than planned into a solution that was given to the infant, according to the coroner's report.

According to Ramsay, an attempt to move quickly was a factor in Mianscum-Kelly's death.

The order to administer potassium was given verbally, and the team wanted to administer it as fast as possible. The mixture was prepared on the spot by a nurse.

Ramsay said negligence was "absolutely not" a factor.

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Change Location. MONTREAL – Sainte - Justine Hospital is raising the alarm after five children were treated for severe burns. Doctors are warning specifically about the use of accelerants (gasoline, butane) to help light campfires and barbecues.

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A few weeks after Mianscum-Kelly's death, 23-month-old Ghali Chorfi died on Dec. 10, 2016.

The toddler had been diagnosed with cancer, and had been hospitalized for 12 days after undergoing a bone marrow transplant.

He soon went into cardiac arrest and was given medication to prevent intravenous stomach ulcers.

According to the coroner's report, he died from malignant arrhythmia induced by the inadvertent injection of a solution of potassium and phosphate that contained a higher amount of potassium than planned.

Hospital takes action

Though the two incidents happened within three weeks of each other, Dr. Marc Girard, director of professional services at Sainte-Justine, said the hospital hadn't experienced this type of error in the 10 years prior.

He said the hospital looked into the entire process surrounding the administration of potassium, starting with the medication's prescription at the time of the incidents.

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CHU Sainte - Justine . Mother and Child University Hospital Center affiliated with the University of Montreal . Pre and post natal care as well as one of the largest pediatric centers in North America.

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"We added supplementary control measures … to ensure that when the product is administered, it's the right dose and the right time," Girard said.

One of the measures is to ensure that as many variations of potassium solution as possible are prepared in advance, either by commercial preparation or at the hospital's central pharmacy.

"[It's] better controlled … in an environment where people are used to doing it," Ramsay said.

Following Ramsay's recommendation to sensitize other hospitals to the dangers associated with the handling of potassium and the necessity to adopt safe practices, the hospital has met with 34 CISSS and CIUSSS's in Quebec to talk about observations and measures taken, Girard said.

Ramsay also recommended that the Ministry of Health and Social Services should make known to all CIUSSS and CISSS institutions its great concern about this death and the dangers of these practices.

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