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Massachusetts Man Dies in Hospital from Medication Error

Sep 13, 2005 | An elderly Massachusetts man entered Brockton Hospital in Boston with bipolar disorder. He was lucid and had no life-threatening illnesses. Unfortunately, four days later he was dead; killed by a massive dose of the wrong medication.

The patient was given 60 times the recommended dose of Librium when he was supposed to have received Lithium.

Even after a nurse discovered the initial mistake, the hospital continued to give the man other antidepressants and sedatives. He also received two doses of antibiotics over six hours late.

As to be expected, the hospital attempted to engage in damage control. When asked if the medication errors contributed to the death, a Hospital spokesman told The Patriot Ledger that autopsy results showed that the man had died of pneumonia.

According to the same spokesman: "When the error was found the doctor and the patient's family were immediately notified. Brockton Hospital immediately launched an investigation and has taken several steps to ensure that this will not happen again."

The errors started when a pharmacist ordered Librium, a sedative taken for anxiety, for the patient instead of Lithium, which he was the drug actually prescribed for his bipolar disorder.

Amazingly, the pharmacist told investigators that even though he realized his mistake immediately, after failing to reach a nurse by telephone, he “forgot to follow through” on the matter. There was plenty of time in which to correct the mistake since the medication was not administered until the next morning.

While the two drugs have similar sounding names, the safe dosage for each is vastly different. A safe dose of Lithium runs up to 600 milligrams a day. The recommended dose of Librium for elderly people, however, is but 5 milligrams two to four times daily.

Thus, the patient received 300 milligrams of Librium, a full 60 times the safe dose of a drug he wasn’t even supposed to receive.

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