How Medical Tech Gave a Patient a Massive Overdose
Bob Wachter has a very interesting and detailed (five parts) report at Backchannel of how design and procedural flaws resulted in a patient’s being given a dose of antibiotics 29 times what it should have been. His article begins:
The nurses and doctors summoned to the hospital room of 16-year-old Pablo Garcia early on the morning of July 27, 2013, knew something was terribly wrong. Just past midnight, Pablo had complained of numbness and tingling all over his body. Two hours later, the tingling had grown worse.
Although Pablo had a dangerous illness—a rare genetic disease called NEMO syndrome that leads to a lifetime of frequent infections and bowel inflammation—his admission to the University of California, San Francisco Medical Center’s Benioff Children’s Hospital had been for a routine colonoscopy, to evaluate a polyp and an area of intestinal narrowing.
At 9 o’clock that night, Pablo took all his evening medications, including steroids to tamp down his dysfunctional immune system and antibiotics to stave off infections. When he started complaining of the tingling, Brooke Levitt, his nurse for the night, wondered whether his symptoms had something to do with GoLYTELY, the nasty bowel-cleansing solution he had been gulping down all evening to prepare for the procedure. Or perhaps he was reacting to the antinausea pills he had taken to keep the GoLYTELY down.
Levitt’s supervising nurse was stumped, too, so they summoned the chief resident in pediatrics, who was on call that night. When the physician arrived in the room, he spoke to and examined the patient, who was anxious, mildly confused, and still complaining of being “numb all over.”
He opened Pablo’s electronic medical record and searched the medication list for clues that might explain the unusual symptoms.
At first, he was perplexed. But then he noticed something that stopped him cold. Six hours earlier, Levitt had given the patient not one Septra pill—a tried-and-true antibiotic used principally for urinary and skin infections — but 38½ of them.
Levitt recalls that moment as the worst of her life. “Wait, look at this Septra dose,” the resident said to her. “This is a huge dose. Oh my God, did you givethis dose?”
“Oh my God,” she said. “I did.”
The doctor picked up the phone and called San Francisco’s poison control center. No one at the center had ever heard of an accidental overdose this large—for Septra or any other antibiotic, for that matter—and nothing close had ever been reported in the medical literature. The toxicology expert there told the panicked clinicians that there wasn’t much they could do other than monitor the patient closely. . .
But read the whole thing. The meat of the article is laying out all the factors that led to the overdose.