Toddler Dies After Doctor’s Decimal Point Error Causes 10x Potassium Overdose, Lawsuit Claims

A.J. O'Leary

November 13, 2025

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Toddler Dies After Doctor’s Decimal Point Error Causes 10x Potassium Overdose, Lawsuit Claims

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A 2-year-old Florida boy died after a doctor allegedly deleted a decimal point in his prescription, causing him to receive 10 times the intended dose of potassium, according to a new lawsuit.

De’Markus Page suffered a fatal potassium overdose on March 3, 2024, leading to a massive brain injury. He spent two weeks on a ventilator before being removed from life support, the lawsuit filed by his mother, Dominique Page, claims.

The suit names the University of Florida Health, Shands Teaching Hospital and Clinics, and several medical staff members, accusing them of gross negligence. It alleges that doctors took 20 minutes to intubate De’Markus after he went into cardiac arrest, and that multiple safeguards failed to catch the dangerous dosage error.

Dosage Error That Proved Fatal

De’Markus, who reportedly had signs of autism and was a picky eater, was first admitted to AdventHealth Ocala Hospital on March 1, 2024, for a virus and low potassium levels. He was later transferred to Shands Hospital in Gainesville for advanced care.

Medical staff noted he weighed just 21 pounds—in the 30th percentile for his age—and continued electrolyte replacement therapy. The next day, Dr. Jiabi Chen allegedly ordered a new potassium dose ten times higher than the previous day’s prescription by deleting a decimal point—changing 1.5 mmol to 15 mmol twice daily, according to court documents.

At the time, De’Markus was already receiving potassium through IV fluids and Pedialyte, further compounding the overdose risk. The hospital’s pharmacy system even flagged the excessive dosage, but the warning was reportedly ignored.

De’Markus received two massive doses, the last at 8:28 p.m., and by 9:02 p.m., he went into cardiac arrest caused by hyperkalemia, the lawsuit says.

Botched Emergency Response

The complaint states that hospital staff made “2 to 3 failed attempts” to intubate the child, with 20 minutes passing before oxygen was restored. Although his heart began beating again, the oxygen deprivation caused catastrophic brain and organ damage.

De’Markus was kept alive for two weeks, suffering seizures and severe ICU complications, until his family made the heartbreaking decision to end life support on March 18, 2024.

Family’s Fight for Accountability

Dominique Page, of Marion County, Florida, is suing for at least $50,000 in damages, citing wrongful death, pain and suffering, and the loss of her child’s companionship.

Attorney Jordan Dulcie, representing the Page family, called the hospital’s conduct “grossly negligent” and said,

“No parent should have to lose a child like this. What the family has endured is unimaginable—and entirely preventable.”

The University of Florida Health declined to comment, citing patient privacy laws. Dr. Jiabi Chen did not respond to requests for comment.

The lawsuit seeks to hold the hospital and its staff accountable and to prevent similar tragedies from happening in the future.

One response to “Toddler Dies After Doctor’s Decimal Point Error Causes 10x Potassium Overdose, Lawsuit Claims”

  1. Stephanie Avatar
    Stephanie

    This is such a heartbreaking and preventable tragedy. It really underscores how critical absolute precision is in medical dosing, especially for children. My heart goes out to De’Markus’s family.

    This case made me wonder about a specific aspect of medication safety that’s often overlooked: what happens when medication is accidentally lost or inaccessible, not due to an error, but perhaps while traveling or during an emergency? While this situation is different from the decimal point error, both scenarios highlight a break in the chain of access to correct treatment.

    I was reading about protocols for this on a medical travel site (sorry for the link, but it helps explain the concept I’m asking about better than I can: https://pillintrip.com/article/what-to-do-if-your-medication-is-lost-or-stolen-while-traveling). It got me thinking—for medical professionals, are there specific, standardized emergency protocols or rapid-response systems in place at most hospitals to verify a prescription’s legitimacy and dosage if a patient or their family arrives without their medication or the original prescription paperwork? How do they quickly ensure they are administering the correct, intended dose to avoid a tragic error, especially under time-sensitive circumstances?

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