US boy, 2, dies of overdose after doctor allegedly gives 15mmol instead of 1.5mmol of medicine

A two-year-old boy in the U.S. died after a doctor allegedly deleted a decimal point from his prescription, from 1.5 to 15, causing him to receive 10 times the intended dosage of potassium, reported the New York Post.

The child, De’Markus Jeremiah Page, died on Mar. 18, 2024 following what his family describes as a “preventable” medication overdose and a delayed emergency response at UF Health Shands Children’s Hospital.

His mother, Dominique Page, has filed a wrongful death suit against the hospital, its parent institution, the University of Florida Health, and several members of its medical staff.

Deadly one decimal mistake

According to the lawsuit, Page was admitted to AdventHealth Ocala Hospital on Mar. 1, 2024 after suffering from vomiting, diarrhoea, and severely low potassium levels.

Doctors transferred him to Shands the following day for more advanced electrolyte treatment.

At Shands, staff recorded that the underweight toddler, who weighed just 21 pounds, continued to show low potassium levels and ordered “electrolyte replacement therapy”.

His original prescription reportedly specified 1.5 mmol of oral potassium phosphate to be administered twice a day.

However, a doctor, Jiabi Chen, later entered a new order deleting the decimal point in the 1.5 mmol dosage, resulting in a prescription of 15 mmol twice a day, the New York Post reported.

This dose was allegedly administered in addition to two other sources of potassium he was already receiving through intravenous fluids and Pedialyte.

The lawsuit states that the hospital’s pharmacy system even generated a “red flag” warning about the excessive dosage, but the error was not corrected.

The toddler received two of the incorrect doses, with the final one given at 8:28pm on Mar. 3.

By 9:02pm, Page went into cardiac arrest, allegedly caused by dangerously elevated potassium levels, a condition known as hyperkalaemia.

Condition worsens

The family claims that the medical team was slow to respond and made “two to three botched attempts” to intubate the child, with at least 20 minutes elapsing before he was successfully given an airway, during which he suffered severe oxygen deprivation, according to the court documents as seen by the New York Post.

He later sustained what doctors described as catastrophic brain damage.

Page was kept on life support for two weeks, during which he experienced seizures and multiple intensive-care complications, before being pronounced brain dead and dying in his mother’s arms on Mar. 18 as reported by the Daily Mail.

Gross negligence

Dominique Page said in a statement quoted by the Alachua Chronicle:

“Every day I wake up and look for my son, and he’s not there. He’s gone, and he didn’t have to be… They killed my little baby boy and never acknowledged any of their wrongdoing. This is every mother’s worst nightmare.”

The family’s lawyer, Jordan Dulcie, described the hospital’s handling of the case as “grossly negligent” and said the mistake highlighted wider concerns about paediatric safety protocols and the monitoring of children with special needs.

“No parent should have to lose a child like this,” he said, as reported by the New York Post. “What the family has endured is unimaginable, and the worst part is that it was entirely preventable.”

Hospital response

UF Health Shands Hospital declined to comment on the specifics of the case, citing patient confidentiality regulations, telling the Daily Mail:

“UF Health is committed to protecting the privacy of all patients and their families… We cannot release information on patients or possible patients and their treatment without consent.”

The lawsuit seeks at least US$50,000 (S$65,100) in damages for wrongful death and for the “mental pain and suffering” Page’s mother endured.

Top images via ClaireRoya14724/X