National Institutes of Health officials said yesterday a young boy died two weeks ago because hospital workers there mistakenly gave him an intravenous saline solution more than five times stronger than the doctor ordered.
Dr. John L. Decker, director of the NIH Clinical Center, called the death of John William Frombach on Jan. 27 a "frightful error." He said two nurses and a supply room worker have been put on administrative leave while the incident is investigated.
The 20-month-old Philadelphia boy came to the clinical center Jan. 21 for a week of diagnostic studies of a congenital adrenal gland problem. He died six days later, a day after the solution was given to him.
Decker said the child's gland problem was serious but not life threatening. He also suffered from an unrelated mental retardation.
"It's an awful thing, a tragedy," said the child's aunt, Ruth Frombach of Philadelphia. "You wonder how things like this happen." She said her nephew, the youngest of five children, had trouble learning but seemed to be progressing. "His favorite toy was a boat with a duck on it, and he was learning to grab for that," she added.
Mark Levy, a lawyer for the child's parents, said they are "devastated" by the death. They declined to be interviewed.
Levy said that the parents are planning to sue NIH for $3.5 million and that preliminary legal papers were mailed to NIH yesterday.
Decker said a doctor had ordered a 0.9 percent saline solution for the child after he developed a middle-ear infection. The physician feared that together with the adrenal condition it would cause dehydration and salt loss.
Computer records show the doctor correctly ordered a normal saline solution with 5 percent dextrose, a type of sugar, Decker said.
But a 5 percent saline solution was used instead, Decker said, which was more than five times stronger than what the doctor had ordered.
The saline solution was started at 10 p.m. on Jan. 26, Decker said. At 4 a.m. the next day, the boy's father, Joseph Frombach, who was sleeping in the same room, called nurses to tell them his son was breathing strangely, according to Decker. The nurses found the boy was in a coma.
Decker said doctors at first believed the child had developed meningitis as a result of his ear infection and placed him in the intensive care unit. He was transferred to Children's Hospital by ambulance at 9:15 a.m.
At about the same time, Decker said, a blood test showed so high a level of salt in the blood that doctors thought there might have been an error in measuring. But doctors at Children's Hospital found the same high level.
One of them, Decker said, noticed that the saline bottle that had been transported with the boy and then discarded was clearly labeled a 5 percent solution.
Doctors started a complete blood transfusion, Decker said, but it was too late and the boy died at 10 p.m. Decker said the child had received 700 cubic centimeters of the solution and death was probably certain long before the mistake was realized.
"It was a terrible tragedy and it has upset the entire staff here to a considerable degree," Decker said. He said the boy's father was quickly told the full details and "the fact that he has a legal claim against the U.S. government was made plain."
Decker said the death was "a very, very freakish accident -- a one in a million chance. There's no excuse for it, and I'm not trying to make one. It's just extraordinary. It's a hospital's job to be safe, after all. You come to the hospital understanding that they will do the right thing." Staff writer Su