Accidents
Healthcare - Drug Error
11th April 2001 Washington DC, a surgeon prescribed 1/2 mg of intravenous morphine to be administered every 4 hours to manage post operative pain for a 5 month old baby. An administrative error led to the prescription being wrongly transcribed as 5 mg in the patients note. An experienced nurse on the ward did not question the unusually large dosage. 4 hours later the baby died of cardiac arrest.
The human brain works using patterns and when tired or relaxed, automatic cognition can miss vital pieces of information.
COST
DEAD: INFANT
COMPANY: LITIGATION
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