I very nearly injected a premature baby that had Down Syndrome with ten times the amount of Lasix I was supposed to give him: I had put the decimal in the wrong place when I did the maths on the dose.
That baby would almost certainly have died if I’d given it to him. I had the liquid drawn up in the syringe and had the syringe actually in the port ready to push through before I looked inside the chamber and realised how uncharacteristically full it seemed. Paediatric IV doses of anything are simply tiny. I was supposed to give him 0.1 mls, and nearly gave him 1.0mls.
I needed a very large cup of tea after that.
Lethal Pt. II
Edit: people are asking how this happened, why no one double checked the dose. That afternoon there was a couple who had a history of combative behaviour and who had also assaulted a doctor four cots down who had come in to see their drug withdrawing baby. They were yelling at the nurse who was taking care of their baby, and the woman who was with me said to me, ‘You’re right with this aren’t you, Janie?’ and hightailed off to make sure that the nurse was safe and to try and de-escalate the situation. The yelling and disruptive environment, and also because I was distracted by that, is most likely why I made the mathematical error in the first place. I did end up telling someone what happened after I had calmed down, and the one of the upshots of this was that that particular couple was given a behavioural order for the Special Care Nursery.
Also, double checking is in no way a failsafe, though of course it can and does help. Thing is: two people will see exactly the wrong thing, and both think it’s the right thing. A few years after this incident I was the victim of a drug error myself when I was in hospital and I was given twenty times the intended dose of morphine. Two nurses had looked at the order, drawn it up, came to my bedside, checked my ID tag, checked the dose again and then given it to me. Drug mistakes are an unfortunate reality of being in hospital, and people will always somehow ‘get around’ the rules and checks and balances and manage to make them.
When I was in high school, I was dating this guy for a few months. I decided to send him a nude while I was getting ready for school. I took the picture, attached a detailed sext (even though the most we had ever done was over the clothes touching…) and hit send and finished up getting ready.
5 minutes later, I’m in the back seat of my mom’s car and I opened my phone to check for a reply. I realized I sent it to my mom instead. I silently freaked out before I realized she obviously hadn’t seen it yet or else everything wouldn’t be so calm right now. I saw her purse on the console between the front seats, phone peaking out with a text notification. I grabbed it as quickly as I could, she asked what I was doing and I just said “I’m checking to see if I’m getting texts.” I deleted it, TRIPLE checked, and deleted all evidence from my own phone too.
I’m almost 24 now and I still am super cautious any time I send anything even slightly questionable to anyone. I won’t text my sister something with a curse word in it unless I check the recipient box twice.