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A cancer patient died after being given 10 times the dose of chemotherapy medication ordered by his doctor. The patient was to receive 50 mg of the medication ordered by his doctor, but was instead given a 500 mg dose. Four days later, the patient died. There were a number of allegations that the hospital staff tried to cover up the error.

Fortunately, the hospital disclosed the error to the family and instituted a number of measures to prevent medication errors.

In a hospital setting, delivery of the appropriate medication is a team effort. The doctor must clearly communicate the prescription to the nursing staff which must in turn accurately communicate the prescription to the pharmacy. The pharmacy must then accurately fill the medication which must be given to the patient in accordance with the doctor’s orders. Communication is key to assuring patient safety, and if there is any doubt as to the doctor’s orders, those issues must be resolved before giving the medication to the patient.

Health care professionals sometimes talk about the “five rights” for giving a patient medication: the right patient, the right medication, the right dosage, the right time, and the right means. Failing to get all five things right puts the well-being of the patient at risk, and can be the basis for a lawsuit against the responsible health care professional.

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