Islam "Izzy" Yasin Ibn Saddiq Peterson, shown a month ago in Tripler Army Medical Center, is in a vegetative state.

Tripler mistake
prompts lawsuit

An infant is left in a vegetative
state after a tank is switched

» Steps to safety

A Tripler Army Medical Center neonatologist had no need to administer any gas to a newborn who was mistakenly given carbon dioxide that left him in a vegetative state, attorney Rick Fried said.

Fried filed a lawsuit against the federal government in U.S. District Court yesterday on behalf of 6-month-old Islam "Izzy" Yasin Ibn Saddiq Peterson and his parents, Dwight and Shalay Peterson. At 8:10 a.m. Jan. 14, Izzy was born healthy at 7 pounds, 5 ounces at Tripler, where he was delivered by scheduled Caesarean section in Operating Room 10, according to the lawsuit.

A neonatologist gave Izzy oxygen to "pink him up," Fried said. Forty-two minutes later when the tank drained, the neonatologist realized that she mistakenly gave the infant carbon dioxide, Fried said.

Izzy, now 16 pounds, 8 ounces, has suffered permanent brain damage and blindness and remains in a vegetative state, Fried said, noting that he will be dependent on breathing and feeding tubes for the rest of his life.

The suit alleges that Tripler staff mistakenly administered carbon dioxide instead of oxygen, resulting in severe brain damage.

A combination of errors led to Izzy's condition, Fried said.

Attorney Rick Fried held up a photo of an oxygen tank that should have been used, left, and a photo of the carbon dioxide tank that was mistakenly used, demonstrating at a news conference yesterday that they were plainly labeled.

He added that the U.S. Army had made an offer after a claim against the federal government was filed in March, but it was rejected.

The carbon-dioxide tank should not have been in the room at all, he said. "It was scheduled C-section. They were the first scheduled that morning. There was no need to have anything but oxygen in that room."

On March 22, more than two weeks after the claim was filed, the Department of Defense's Patient Safety Center issued a patient safety alert notice informing all military medical staff of the Jan. 14 incident. It stated that Izzy was given oxygen because of "weak spontaneous cry and poor muscle tone" and that the oxygen tubing was mistakenly attached to the carbon dioxide tank.

On Friday, Izzy, his family and more than 20 medical staff members took a flight from Hickam Air Force Base to Wilford Hall Medical Center at Lackland Air Force Base in San Antonio. His father, an Army sergeant, was transferred to Fort Sam Houston Army Base.

Fried said Izzy will need round-the-clock care. Costs to care for him are estimated at more than $20 million for the rest of his expected life.

In a written statement, Tripler officials said: "Tripler Army Medical Center staff has provided the Peterson family with as much comfort and dignity as was possible following this tragedy. Our focus has been to support the family in any way we were able.

"The Army will continue to try and settle the case," they further stated. "Regarding specific litigation, we are not able to comment. We have completed gathering the information and facts, and have taken immediate corrective action. ... Tripler staff expresses sorrow and deep sympathy regarding the Peterson family situation. We are very sorry this happened."


Steps to safety

In March the Department of Defense issued an alert of the Jan. 14 "medical gas sentinel event" to all military medical personnel. It also included a list of interventions to minimize the risk of a similar incident in which a newborn was given carbon dioxide instead of oxygen. Some of the interventions:

» Implement policies that require the facility piped-in oxygen system to serve as the primary source for oxygen. Staff should only use portable oxygen tanks for patient transport and, if needed, to back up failure of the central piped-in system.

» Replace all green and other colored "Christmas tree" adapters with ones that are clear to avoid reliance on adapter color to identify the gas type (green adapters were used for both the oxygen and carbon dioxide tanks).

» Use an oxygen analyzer to ensure that the patient is getting oxygen and not another type of gas such as carbon dioxide.

Source: U.S. Department of Defense's Patient Safety Center

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