Technology led a hospital to give a patient 38 times his dosage
Cliff notes--
New EMR&#x2F;ordering system. New physician. New nurse. New pharmacy dispensing system. The physician couldn&#x27;t order 160mg of Bactrim because per kg dosing was required. They mistakenly ordered 160 &quot;mg&#x2F;kg&quot; (40x the intended dose of 4mg&#x2F;kg) on the order screen. The UX on the screen was partly to blame-- dosing mg or mg&#x2F;kg apparently came down to a just a dropbox. With EMR ordering systems I&#x27;ve used, this mistake is virtually impossible to make since weight-based dosing pops up a completely different window, calculates the dose and then goes back to the original dose screen showing the total dose.<p>That order went to a pharmacy robot which diligently counted out 40pills, put them in baggies and sent them to the nurse. The nurse thought it was strange, but ultimately trusted the dispensing system that said everything was correct.<p>The medication error was noticed after the kiddo felt whole-body tingling. Poison control was called, but it didn&#x27;t seem like they were able to give a clear treatment advice. A &quot;rapid response&quot; was called, they came and evaluated the patient. He was left in a non-ICU room. Several hours later he had a seizure. He recovered from the seizure and was then monitored in the ICU.