Patient died from 8GMs of Dilantin

-The nurse had to get THIRTY-TWO vials of Dilantin from 3 seperate Pyxis units.

-The nurse had to start a second IV to administer that much Dilantin.

All of this would have also taken some time, time enough to think about what she's doing. And the nurse didn't question 32 vials and having to go to 3 pyxis units? I learned that if you have to use more than three, to double check.

Ok, I know this wasn't suggested anywhere as yet, but the only thing I can POSSIBLY imagine that could cause an experienced nurse to be this far off base is if she was so severely distracted, perhaps under the influence of something, that she simply could not think straight.

There's just no other reasoning, in my mind for this scenario going through the nurse's head: "MD has just told me to give 8000 mg of Dilantin. Ok, I'll go get the med from the Pyxis. Hmmm, according to my math I'm gonna need alot more than what's here; I need 32 vials. Ok, I'll gather it all. Gee, wonder why there's only ten in this one? And only ten in that Pyxis? Man, I'm cleaning out ALL the Dilantin from the unit! Ok, have it all. Drawing up vial one.....four.....seven.....nine....gee, seems like alot of work. Drawing up vial 11.....17.....20.....24. Whew, this is taking ALOT of time! Never had to do THIS much Dilantin before. Never saw anyone else do this either. Oh, well....drawing up vial 27.....30....32! Gonna need two bags for this....and start another IV. Gosh, I hope I don't have to do this again in a few hours!"

Which is why I can't imagine a sober, non-impaired nurse doing this.

I don't understand what the doctor did wrong.

I have NO idea how she gave that much dilantin. That's makes NO sense.