This case is prompting a lot of comments, some of them taking issue with the concept of systemic failures and instead asserting that the young nurse was clearly incompetent, in that her error was inexplicable. So, let’s turn from a clinic in Brazil to a recent case in a hospital in the US, cited in this article on AHRQ’s Web M&M. A summary:
The order was written correctly in the electronic medical record (EMR) for phenytoin, 800 mg IV. The drug-dispensing machines stocked phenytoin in 250 mg/1 mL vials. The correct dose therefore would require 4 vials and be equal to 3.2 mL to be added to a small IV bag. The nurse misread the order as 8000 mg (8 g) and proceeded to administer that dose to the patient, which was a 10-fold overdose and 2 to 3 times the lethal dose. The patient died several minutes after the infusion.
This nurse had to work hard to make the error:
An audit of the pharmacy system revealed that the nurse had taken 32 vials out of 3 different pharmacy dispensing machines to accumulate 8 g of IV phenytoin. Moreover, the nurse had to use two IV bags and a piggyback line to give that large a dose.