People Share Their Best “You Messed Up Big Time” Stories

Always Check The Decimals

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I very nearly injected a premature baby who 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 math 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.

JaniePage

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