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A Florida woman died recently of a massive overdose of dilantin while she was hospitalized. The attending physician ordered 800 milligrams of the drug, but a nurse gave her 8000 milligrams instead. Two to five grams is considered a fatal dosage.

Heart failure was a cause of the patient’s death. According to the Institute of Medicine, this was one of the estimated 400,000 patient deaths resulting from medication errors.

The death in this case was a result of systrems failure, including the failure of the doctor to issue clear orders, the failure of the nurse to verify the order, and the failure of the pharmacy to ask for clarification. The dosage in this case required the nurse to use virtually all of the dilantin in the hospital, 32 doses. Despite the red flags that should have been set off, none were and a tragic, avoidable death resulted.

Also of note: the civil action against the hospital for the death of this unfortunate woman was settled by her husband for $200,000. The accident happened in Florida, where damage caps are low and have been in place for a long time. Anyone still think that they are a good idea?

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