Great Catches: The pause that saved a child

UF Health recognizes staff members who have made great catches that have prevented medical errors

By: Morgan Sherburne

Each month, the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety recognizes staff members who have made great catches that have prevented medical errors.

When an order for a 650-milligram dose of acetaminophen came to Shimaa Ghonim, Pharm.D., through Epic, the electronic medical records system, she paused.

Thomas Johns, Pharm.D., and Shimaa Ghonim, Pharm.D.

Thomas Johns, Pharm.D., and Shimaa Ghonim, Pharm. D.

The dose was the amount usually given to adults. Ghonim, who is a pediatric clinical pharmacist at UF Health Shands Hospital, thought perhaps the medication was for a larger child, the size of an adult.

“But then I saw that the patient was 6 months old and weighed 4.7 kilograms (10 pounds), and I thought, ‘Oh no,’” Ghonim said.

Ghonim called the provider who ordered the dose, and the dose was corrected before it could reach the patient. If the patient had been given the ordered dose, the overdose of acetaminophen could have caused major liver damage.

Ghonim, who was given a “Great Catch Award” by the Sebastian Ferrero Office of Clinical Quality and Patient Safety, earned her Doctor of Pharmacy degree at the UF College of Pharmacy. She then completed her clinical residency at UF Health Shands Hospital, finishing in 2011.

“I was interested in pediatrics to begin with,” Ghonim said. “Luckily, I ended up here. It’s very collaborative: We work closely with physicians and nurses. We go on rounds with the team in the mornings and come up with treatment plans together — actually, I love my job.”