Patient died from 8GMs of Dilantin

http://www.sun-sentinel.com/features...,2507778.story

I read this story this morning, and I'm still trying to get over the shock. According to the news report, an ER physician ordered 800mg of dilantin IV, but the nurse gave 8,000mg, and, not surprisingly, the patient died almost immediately afterwards.

I used to work at this hospital, and I know its a zoo and that the nurses there are stressed out, but thats because the hospital is so huge and there are so many patients. I have nothing bad to say about the hospital either because, the usual politics aside, its a decent place to work and they do invest a lot of money in facilities, equipment, and staff training. I just cannot understand how this nurse could have made such a mistake, especially with a drug like Dilantin. 8,000mg is a LOT! To get that much dilantin together you would have to get a ridiculous number of vials from the the Pyxis. Even if you were pulling all these vials to give such a dose, there must be some point at which you would stop and think to yourself 'this doesn't make sense', and at least re-read the order or ask somebody else to check it with you. According to the report, she used a whopping 32 vials of the drug!!! How will she ever explain this to the BON. I would love to hear her side of the story. She's apparently not talking, and I can't say I blame her because no matter what she says she's probably going to lose her license anyway, and maybe she'll even get sued for everything she's got.

This has to be the scariest medication error I've ever heard of. Very sad situation for the patient and her family.

I feel terrible that the patient has died.

I feel terribly for the nurse who committed the drug error.

I am going to try my very best to refrain from playing the 'blame game' while composing this response. However, (s)he should have clarified the order with the doctor because an 8000mg dose of Dilantin sounds absolutely ridiculous and unheard of. Better yet, she should have used some common sense to get through this situation without any tragedy.

Sorry but a spade is a spade. That was pretty dumb. End of story.

Too bad no one was there at the pyxis, watching her mix that mongo load of Dilantin, to stop her. I know of people who have done worse in my area and not lost their license.

All I can say is wow...what a terrible tragedy. A number of red flags should have gone up and she didn't respond to any of them. 32 vials of Dilantin???

What's weird to me is that after nine years of nursing, she made a mistake like that? Dilantin IV is fairly common down here.

Absolutely inexcusable. Also, think about how long it took to draw up 32 vials of med. It seems odd that no one else saw what she was doing and made an attempt to intervene.

I don't understand what the doctor did wrong.

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

Right. I thought ER nurses gave IV Dilantin regularly.

"The correct dose required 3.2 vials of the drug. Cooper gave Plass 32 vials, hospital administrator Joe Scott said. To get that many, she had to search the halls and take every vial from three computerized drug-dispensing machines, he said. "That would be a big red flag," Scott said.

All the Dilantin didn't fit in one intravenous bag, so Cooper hooked up two, one in each arm, Scott said. "That would be another big red flag," he said."

Wow.