Shands hospital says it's their fault that a three year old boy died in their care. Sebastian Ferrero got more than ten times the prescribed dosage of the amino acid arginine. The error cost Ferrero his life.

But the mistake has been made before. Two months before, another boy received a dangerous dose of arginine. Kaleb Mayberry's doctor recommended a routine growth hormone stimulation test, however the results were not routine at all. The boy's mother Jessica Mayberry explained, "In his file, he was described as having a mild headache. I don't know what part of writhing on the floor and screaming my head is on fire is mild, but that enraged me."

And what these two cases tragically highlight is the need for solutions to preventing human error in the medical system. While it was mistakes that caused these two families much grief the cases have stirred up questions over the treatment.

Some children are not as big as their friends and there are times when parents decide to find out if there is a medical reason for it. While testing for a deficiency in human growth hormone, this near-fatal case and one death have given parents pause to ask some key questions about their children's health.

Dr. Donald Novak of Shands at a press conference on October 25, offered the following, "...we are terribly sorry that this happened..."

Those are the solemn words of a public apology Shands gave Luisa and Horst Ferrero. The death of their son Sebastian has again stirred questions over the use of growth hormone therapy for children.

Dr. David Katz of Yale Univesity's medical research center says that growth hormone therapy has both the potential to do good as well as harm.  In an interview with TV20 today Katz, said, "Any hormone therapy is potentially quite dangerous, because you're manipulating the inner workings of the body."

Even the best intentions of parents can end with the worst results as Mayberry's parents learned. "When you're a mother, you're your child's advocate. so it's up to me to look out in his interest, he really hates being small," said Mayberry.

Katz says a child who is shorter than expected may not be growing as anticipated signifying a  hormonal imbalance. However, Katz adds, "If there isn't an abnormality, there are other things can be used to maximize growth, a healthy diet, exercise,...just the basic activities of healthy living."

It's up to medical professionals to determine whether your child's size is far from normal -- or if their situation warrants medical testing. Katz says there are key questions parents need to ask. "Is this the expected healthy growth rate for this child? Or is something potentially wrong and should we investigate that?"

The Ferrero's never got beyond testing for abnormalities in Sebastian's  growth hormone levels. "This is simply the case where the dose makes the error in the dosing of arginine led to a tragic and fatal mistake," added Katz.

The Institute of Medicine published a report in 2001 about human error in medicine --and found that it is a leading cause of death in the United States.

Stacey Samuel