Brigham newborns got Tylenol overdose

A nurse at Brigham and Women's Hospital gave two newborn boys a tenfold overdose of Tylenol on Sunday, and the state and the hospital have launched investigations to determine how the error occurred. Doctors said the babies appear to be healthy.

''There was no harmful impact to them," said Dr. Andy Whittemore, the hospital's chief medical officer.

He said that Tylenol overdoses can harm the liver, but that liver toxicity tests on the two newborns showed no serious problems. One child was discharged yesterday and doctors planned to send home the other child today. Doctors gave the babies an antidote to Tylenol.

The nurse gave the babies, who required Tylenol after they were circumcised, 4 cubic centimeters of the pain medication, rather than the correct dose of 0.4 cubic centimeter. One of the babies' mothers discovered the error, which was repeated on her instructions for giving her son a second dose at home.

''She called in to check," Whittemore said. ''It just didn't feel right."

The mother mentioned that the baby next to her son also appeared to get the same large dose of Tylenol, which is a liquid given to the babies orally in a syringe.

Medication errors are one of the most common mistakes in hospitals, and they have a variety of causes, including doctors writing wrong doses and nurses misreading their handwriting. The Brigham has been on the forefront nationally in installing special computer systems to help prevent drug errors. One of these systems, in which doctors order drugs on the computer to eliminate handwriting errors, has not yet been installed in the hospital's newborn nursery, Whittemore said.

He said he did not know whether the problem was messy handwriting or some other error, but Whittemore said the Brigham will uncover the cause and find a way to prevent similar problems.

After the mother called, he said, the hospital reviewed medications given to other babies that day, but found only those errors.

The Department of Public Health is also investigating the mixup, which the Brigham reported to state officials yesterday.

Liz Kowalczyk can be reached at kowalczyk@globe.com.