One comma erased from a prescription, and the dose was multiplied by ten. In Florida, the family of 2-year-old De’Markus Jeremiah Page is accusing UF Health Shands Children’s Hospital in Gainesville of a fatal potassium phosphate overdose, according to a medical negligence lawsuit. The little boy, hospitalized with a virus and an electrolyte imbalance, did not survive.
A tragic tragedy, which could have been avoided
The facts date back to March 1, 2024. First admitted to AdventHealth Ocala for vomiting, severe diarrhea and stopping eating, the little boy was transferred to Gainesville for more serious care. Upon arrival, the little one was admitted to a simple pediatric unit, even though he should have received intensive care.
A prescription for oral potassium phosphate at 1.5 mmol, twice a day, is given based on their height, weight and analyzes. Without close monitoring of electrolytes or cardiac monitoring, the child falls into hyperkalemia and goes into hyperkalemic cardiac arrest. The staff would not have immediately detected it, with a delay of at least 20 minutes before a resuscitation attempt and two to three unsuccessful intubation attempts, the emergency equipment being considered insufficient by the family.
Circulation returns briefly, but oxygen deprivation results in severe brain injury. The child remained oxygenated in pediatric intensive care, before being declared brain dead and passing away on March 18, 2024, in his mother’s arms.
© Dominique Page on Alachua Chronicle
2-year-old dies after comma error in prescription, family sues Florida hospital. Dominique Page for Alachua Chronicle
The family takes legal action and accuses the hospital of negligence
“Every day I wake up and look for my son, and he’s not there. He’s gone, and he shouldn’t have been. We were sent to Shands Hospital from another hospital, and we trusted Shands Hospital for its care. They killed my little boy and never admitted any wrongdoing. It’s every mother’s worst nightmare“, declared Dominique Page, the child’s mother, in a press release relayed by Alachua Chronicle.
At the beginning of November 2025, the family filed a lawsuit for “wrongful death” and medical negligence, targeting the institutional liability of the establishment. According to the complaint, the comma between 1 and 5 disappears in the electronic file and the dose becomes 15 mmol, or 10 times the planned dose, in addition to the potassium already administered intravenously and by rehydration drink.
“No parent should have to lose a child like this“, says lawyer Jordan Dulcie. “What this family went through is unimaginable, and the worst part is that it could have been entirely avoided. I pledge to hold UF Health Shands Children’s Hospital fully accountable and present this case before a jury to prevent such heartbreak from befalling another family“. The hospital did not wish to comment, citing the protection of patient privacy
Illegible writing and dosage errors
Illegible handwriting by doctors is a major cause of dosage errors: in the United States, it is responsible for more than 7,000 deaths each year according to a report by the Institute of Medicine published in 2006, and more than 1.5 million Americans are victims of avoidable medication errors annually. In France, such errors remain possible, according to Dr. Gérald Kierzek, emergency physician and medical director of True Medical.but their frequency is decreasing thanks to the generalization of electronic prescriptions, the active involvement of pharmacists and the implementation of double control systems during dispensing.
This progress highlights the importance of standardizing the writing of prescriptions and improving multidisciplinary communication to guarantee patient safety and limit the serious consequences of a dosage error.