Reference no: EM133334787

A 6-year-old patient with a defect in bowel function was hospitalized in his local public hospital (Memorial Hospital) for severe constipation. He was given a dose of neostigmine (a drug that helps muscles contract and relax to move food through the system) that was 10 times the normal amount because of a decimal point error made by the resident medical officer who ordered the drug. Instead of 0.4 mg, the patient received 4.0 mg. Tragically, the patient died the same day from the overdose. The human resources director advised the CEO to immediately hold a press conference to announce this unfortunate event. The CEO did this. The conference lasted for two hours and centered on reporter questions about why the resident medical officer and the nurses involved had not been fired. It was explained that both were highly regarded and that the problem was a "system" problem, not a problem of an incompetence. I explained that there is no fail-safe system in place to prevent human error. The introduction on electronic medication charts may assist in preventing such errors in the future. The CEO indicated to the reporters that the health service would be examining the medication administration procedures in.