Patient died from 8GMs of Dilantin

It wasn't an IV push. The drug was diluted and hung in two bags (hence, the second IV started).

Why didn't the computerized drug-dispensing machines catch that? I'm just a nursing student, and I would have definitely questioned giving 32 vials of any medications to anyone!

And I, too, don't understand what the doctor did wrong.

I wonder if the doc used the "trailing zero"? Instead of writing 800mg, he wrote 800.0mg? Which is one of the no-no's from JACHO to prevent errors like this one.

Still doesn't explain all the other breaks in the process, but could explain how it started...

Right. Even if he'd written for such a huge dose, or even if he ordered verbally to give that much, this is where the nurse's judgment comes in.

Her responsibility to the patient at that point was to realize that this was a dosing error and refuse to administer the medication.

If this nurse was not from the US and was unfamiliar with the language as well as the med, then the error makes more sense to me.

It's just such a tragedy!

What a terrible tragedy. I'm sure we have all heard of fatal mistakes like this before. Hopefully, being made aware of this, we will all remember to always follow the 5 rights of drug administration:
Right drug
Right dose
Right time
Right route
Right client

poor nurse
poor patient
poor family
a tragedy

All very odd

And I don’t care how busy you are that is odd.
32 vials, personally if I’d had to go find 32 of anything when I’m in a hurry and busy I’d be bit*hing to everyone in ear shot.

It really does sound like there is more to this that we’re reading here.
Even if the Doc’s writing was bad or odd you would still ask someone wouldn’t you?

From a personal experience I once had to make up a 24hr pump for a patient with a total dose of 1000mg Morphine, yes ONE THOUSAND MG.

In UK all controlled drugs have to be check by two qualified RNs. I had the chart was getting out needles syringes so that all was ready for when my ‘check nurse’ arrived. (2 RN’s and 2 Care Assistances for 30-bedded ward, on this day we had a full ward, 2 wanderers, restrains are not allowed in UK for confused patients, and 2 DT’ers so we were busy) When I looked at the chart I laughed and called her to read it, commenting that the Doc that wrote this must have been having a bad day. Even the Care assistant laughed.
Called the doc who said no that’s the right dose, we laughed again and said he’d have to come up in person (which he did) because we didn’t think he understood what we were saying.
Called the on call pharmacist (cause these things always happen after hours), who said that they had called her GP and local pharmacy because they couldn’t believe it either. And they’d supplied us extra to make sure we’d have enough.
We called her home care nurses just to check again.
Now we were busy but still made the time to do all the above.
The patient was very patient, stating that this was why they had asked for the pump to be changed early as this always happened.

And even with all that we asked the Matron on duty to come and witness it, that although we knew it was the correct dose we were still worried…………

Does the normal pyxis even hold 32 vials of dilantin? I think of the one we have at work and I'd say no. Pharmacy fills it twice a day, morning and afternoon/evening.

I didn't read all of the other posts but my question is... after a certain point, even before the full dosage of 8,000mgs could be administered, wouldn't some kind of ill effects already have been noticeable? Forgive me if this is a naive question since I am not a nurse yet and only in Pre Nursing classes.

I could be mistaken, but I think the term "red flag" is kind of an understatement in this situation. What the h*** was that nurse thinking? I guess she wasn't....