Question

A nurse in Seattle performed dosage calculations in her head and accidentally administered a dose to an infant patient that was 10 times higher than the prescribed amount.

 

How It Happened

 

The nurse was instructed by a doctor to administer 140 milligrams of calcium chloride to her 8-month-old patient. Thinking that there were 10 milligrams in a milliliter instead of 100, she calculated in her head that she’d need to give the patient 14 milliliters of calcium—a dose that was 10 times higher than prescribed.

 

The Result

 

By the time the nurse’s team discovered the mistake, it was too late. The baby girl died five days later.

 

 

 

Answer 1