Monthly Archives: July 2015

“The Overdose” – Story of an overdose at my new home institution

One of my favorite non-medical websites to visit when I’m looking for something to occupy my internet time with is It’s a blog that collects and publicizes links to what it considers the best of “longform journalism”, AKA literary non-fiction AKA a mix of essays, reporting, and occasionally short stories. I think perhaps it’s the pace with which they publish things, and the resultant quality and consistency, that makes this better in many ways than other aggregators of content, but your mileage may vary.

Anyway, the article describes over its five parts how a pediatric patient with a chronic metabolic disease, through a series of oversights and mistakes (I’ll avoid using the term “accident” here, without implying that this was intentional or grossly negligent), received a whopping dose of almost 6.5 grams of Bactrim DS, or 38.5 times the dose that the patient should have received. This mistake originated when the requirement for weight-based dosing in pediatric patients met some built-in alarm systems that notify pharmacy and then require manual entry from the ordering provider when the rounded dose (taking into account the actual dosing given pill contents) differs from the ordered dose by > 5%. When the pharmacist contacted the resident and asked that she modify the order, the requested dose of 160 mg was entered as 160 mg/kg. A robot in the pharmacy pulled the meds and dispensed them into a baggie that was bar-coded and labeled, and a pharmacist missed the opportunity to recognize the overdose before the bar-coded baggie was sent to a nurse. When asked later on, the nurse said she had a weird feeling about giving so many pills to a child, but assumed that since it was ordered, dispensed by the robot and the pharmacy, and it was unquestionably for the right patient (barcodes ensured this) she gave it anyway.

The patient, a teenager, very quickly thereafter became symptomatic of his overdose and seized, followed by a brief period of apnea. There was a rapid response and a transfer to the PICU and ultimately he was okay. So no harm, no foul, right? Sort of. Obviously, mistakes were made here– it should be incumbent on ordering providers to make sure the details of each order they sign are correct, especially in terms of the dose. But there were so many systemic contributing factors in play, that the the changes required to avoid this happening again were more institutional than individual. In emergency medicine particularly, where orders are entered quickly and under pressure, it is interesting to consider how failsafe mechanisms and provider order entry-assistance tools can both prevent and enable medication errors and other patient safety hazards. As medicine becomes increasingly interwoven with computers and providers off-load more and more cognitive work onto the computer systems they work with, telling these stories and learning from them will be evermore important.

“How Technology Led a Hospital To Give a Patient 38 Times His Dosage” –

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