MedMal - The Wrong Medication, The Missing Checklist, No Timeout

A Two-Day-Old Who Didn't Have to Die

A California doctor is facing felony involuntary manslaughter charges. A two-day-old boy is dead. The cause of death was opioid toxicity from a drug that should never have been anywhere near a newborn during a routine circumcision. This case is a tragedy. It is also a teaching moment that every physician who performs procedures should read carefully.

What Happened

On February 27, 2024, Dr. Hong-An Jan performed a circumcision on two-day-old Charles Wang at his private clinic in Garden Grove, California. According to the lawsuit and court filings, instead of injecting Xylocaine (lidocaine), the appropriate local anesthetic for this procedure, the physician injected Demerol, a synthetic opioid painkiller classified as a Schedule II narcotic. The toxicology report confirmed high levels of Demerol. There was no lidocaine.

The infant became lethargic and unresponsive.

The physician examined him, told the parents this was a normal reaction, sent them home, and ordered no laboratory tests. The following day, Charles was pronounced dead at the hospital. The coroner ruled the cause of death as bronchopneumonia due to acute Demerol intoxication.

Dr. Jan pleaded not guilty in February 2026. His medical license has been suspended pending the outcome of the case.

PS: According to the report, the doctor earned his medical degree in 1967 which would have likely made him about 80 years old in 2024. Commercial airline pilots in the United States are prohibited from flying passengers after age 65 under FAA regulations Federal Aviation Administration — a rule aligned with international aviation standards and based on the straightforward premise that cognitive and physical performance decline with age, and that passengers deserve protection from that risk. Dr. Jan appeared to be in his 80’s when he performed the procedure that killed Charles Wang. There is no equivalent rule for physicians.

A pilot who is 80 years old cannot legally sit in the cockpit of a commercial aircraft.

A physician who is 80 years old can perform procedures on a two-day-old infant in a private office with no oversight, no co-pilot, and no mandatory competency review. Medicine has long resisted what aviation figured out decades ago: that experience and age are not the same thing, and that protecting the public sometimes means protecting it from practitioners who no longer recognize their own limitations.

What does the AARP say

The AAP position on pain control during newborn circumcision is unambiguous and has been for more than two decades. Its 1999 policy statement declared for the first time that analgesia is essential if circumcision is to be performed, citing physiologic evidence that neonates circumcised without pain control experience measurable stress responses including changes in heart rate, blood pressure, oxygen saturation, and cortisol levels. The 2012 AAP Task Force on Circumcision reaffirmed and strengthened this position: adequate analgesia should be provided whenever newborn circumcision is performed, and nonpharmacologic techniques such as positioning and sucrose pacifiers are insufficient as the sole method and should be used only as adjuncts. American Academy of Pediatrics

The three accepted pharmacologic methods are:

1. EMLA cream (a topical lidocaine-prilocaine mixture),

2. the dorsal penile nerve block, and

3. the subcutaneous ring block.

The AAP identifies the ring block as the most effective, while noting that all methods reduce but do not eliminate pain. Circumcision Research Project In this case, none of these methods were used. There was no EMLA, no nerve block, no ring block. What was injected instead was a Schedule II opioid with no role whatsoever in neonatal local anesthesia. The AAP standard was not merely missed. It was replaced by something that killed the child.

Demerol in a Newborn: Why This Is Catastrophic

Meperidine (Demerol) is an opioid analgesic with a narrow therapeutic window in adults. In neonates, it is not just dangerous. It is potentially lethal. Newborns have immature hepatic enzyme systems, particularly CYP2B6 and CYP3A4, which are responsible for metabolizing opioids. They have limited protein binding capacity, meaning a higher fraction of the drug circulates in the free, active form. Their blood-brain barrier is more permeable. The respiratory center in the brainstem is exquisitely sensitive to opioid-induced suppression. A dose that might cause sedation in an older child or adult can cause apnea, hypoxia, and death in a two-day-old.

The medical literature has documented this risk repeatedly. Inadvertent administration of adult opioid doses to neonates and small children is one of the most consistently reported causes of serious adverse outcomes in pediatric patients. The Institute for Safe Medication Practices (ISMP) has published multiple alerts on neonatal opioid overdose from medication errors. The Joint Commission has cited look-alike, sound-alike drug errors as a persistent root cause of sentinel events in newborns and children. This is not obscure knowledge. It is foundational pharmacology.

When an infant is lethargic and unresponsive after a procedure where an opioid has been administered, even inadvertently, even unknowingly, the correct response is emergency evaluation, opioid reversal with naloxone if indicated, and immediate transfer. Not reassurance. Not sending the family home.

The Timeout

Before any procedure, every clinical setting in the United States that follows standard safety protocols requires a formal pre-procedure pause. It is called the Universal Protocol, developed by The Joint Commission and adopted across surgical and procedural medicine. It has three components: a pre-procedure verification, a site marking when applicable, and a time-out immediately before the procedure begins.

The time-out is not bureaucratic theater. It is the last line of defense before a wrong drug, wrong site, wrong patient, or wrong procedure causes permanent harm. During the time-out, the team verbally confirms the patient identity, the planned procedure, and the medications and materials that are about to be used. If the medication drawn into that syringe had been verbally confirmed against the intended agent, the error might have been caught. A nurse saying out loud, ‘Lidocaine, 1%, ready for dorsal penile nerve block,’ is not a formality. It is a checkpoint.

The Universal Protocol was introduced in 2003 after the Joint Commission’s analysis of wrong-site surgeries. Subsequent data showed meaningful reductions in surgical errors at institutions that implemented it rigorously. The WHO Surgical Safety Checklist, adapted globally since 2008, incorporates the same logic. The evidence for structured checklists in procedural safety is not debated. Atul Gawande’s work popularized it; the aviation industry proved it decades earlier. Checklists save lives.

Private office-based procedures present a specific risk here.

Hospitals and ambulatory surgical centers have protocols enforced by accreditation standards, nursing staff, and institutional oversight.

A solo practitioner in a private clinic may have none of those safeguards. No scrub tech to confirm the tray. No circulating nurse to verify the drug. No second set of eyes at the moment the syringe is filled.

This is precisely where a personal pre-procedure time-out, even performed alone and spoken aloud, becomes non-negotiable.

If Dr. Jan had paused before the procedure, looked at the syringe, and confirmed aloud, ‘This is Xylocaine, I am about to perform a dorsal penile nerve block on a two-day-old male for circumcision,’ the question arises whether the wrong drug would have made it into that child’s tissue. We cannot know. But we know that no protocol protected him.

Medication Safety in Newborns and Small Children

Neonates and infants are pharmacologically not small adults. Drug dosing errors in this population are a well-documented patient safety crisis. A 2019 systematic review published in BMJ Quality and Safety found that medication errors in neonatal intensive care units had an incidence ranging from 3 to 73 per 1,000 patient-days across studies, with administration errors being the most common type. ISMP has repeatedly highlighted that neonates are at the highest risk of fatal medication errors precisely because small dose differences produce dramatic clinical consequences.

In the outpatient procedure setting, the risks multiply when there is no pharmacist verification, no unit-dose dispensing system, and no barcode medication administration. In a solo private office, the physician draws the drug, carries the syringe, and administers it without any of the institutional checks that exist in hospital settings. This is legal. It is common. And in the absence of personal discipline and double-checking, it is dangerous.

Opioids and local anesthetics are not look-alike medications by name, but they may share packaging, syringe sizes, or storage proximity in a small office. ISMP has long advocated for physical separation of high-alert medications in clinical environments. High-alert drugs, including opioids, concentrated electrolytes, and anticoagulants, warrant special storage, labeling, and handling precisely because the consequences of error are severe and irreversible.

What Should Have Happened at Discharge

Even if the medication error had occurred and gone undetected at the time of the procedure, the subsequent encounter with the parents represented a second opportunity to avert the outcome. A lethargic, unresponsive newborn in the hours after a procedure is a medical emergency until proven otherwise. The clinical response to that presentation is not visual inspection and verbal reassurance. It is vital signs, oxygen saturation, a thorough neurological assessment, and if opioid exposure is possible under any circumstances, naloxone consideration and urgent escalation.

The lawsuit alleges that the physician neither drew blood nor ordered laboratory studies despite observing symptoms consistent with opioid toxicity. If that is accurate, this is not a close clinical call. It is a failure of the most basic principles of emergency recognition.

My Take

I have performed procedures throughout my career. I have taught residents to perform procedures. The pre-procedure time-out is not something you do because your institution requires it. It is something you do because the alternative is standing in a courtroom explaining why you did not.

Charles Wang was two days old. He did not need to die. The procedural error that killed him may have been prevented by a single verbal confirmation before the procedure began. The failure to recognize and act on his deteriorating condition afterward compounded a catastrophe that was already unfolding.

This case will move through the courts. Dr. Jan has pleaded not guilty and is entitled to due process. But regardless of how the criminal matter resolves, the clinical lessons are not ambiguous. Every physician performing procedures, in a hospital, an ambulatory center, or a private office, should treat the pre-procedure time-out as inviolable. Every practice that stocks opioids alongside other injectable agents should have physical separation and mandatory double-checks before administration. And every clinician who encounters a lethargic newborn after any procedure should treat it as a crisis, not a reassurance opportunity.

Checklists are not an insult to expertise. They are what expertise looks like when it takes safety seriously.

Addendum

Drug dosing in neonates, children, and adults is not a sliding scale. It is a fundamentally different calculation at every stage of development, and the margin for error collapses as the patient gets smaller.

A standard adult dose of an opioid is calculated for a body weighing roughly 70 kilograms with mature hepatic enzyme systems, full protein binding capacity, and a blood-brain barrier that has had decades to consolidate. A two-day-old weighs approximately 3 kilograms. That is a more than 20-fold difference in body mass alone. But weight is only the beginning. Neonatal and pediatric patients can vary in weight from 0.5 kg to over 100 kg, creating the potential for a 400-fold dosing error, compared to a maximum of roughly 2-fold in adult patients.

PubMed Central In neonates specifically, the cytochrome P450 enzyme system that metabolizes opioids is functionally immature at birth and does not reach adult capacity for weeks to months depending on the specific enzyme. Renal clearance is similarly limited. A tenfold dosing error in a child can occur from a single misplaced decimal point and may go undetected because the resulting dose still falls within the normal adult range NCBI — a range that is physiologically lethal in a newborn.

This is precisely why weight-based dosing in mg/kg is mandatory in pediatric pharmacology, why neonates require entirely separate dosing references, and why any opioid administered to a newborn outside of a controlled neonatal intensive care setting with continuous monitoring is a high-alert event by definition. In a private office, with no pharmacist, no barcode verification, and no second check, that margin for catastrophic error is entirely dependent on the physician drawing the correct drug into the correct syringe. In this case, that did not happen.