You’re Getting Sleeeeepy… TOO Sleepy!
DOCTOR/PHYSICIAN, HOSPITAL, IGNORING & INATTENTIVE, NEW JERSEY, PHARMACY, USA | HEALTHY | NOVEMBER 19, 2020
I used to volunteer with my township’s all-volunteer first aid squad. One day, we receive a call to respond to the house of a couple in their sixties.
Wife: “My husband isn’t acting right and I’m having trouble waking him up.”
Upon arriving at the house, my partner and I walk into the spare bedroom where the husband has been taking a nap. He is extremely lethargic and we have trouble even getting him to answer any questions. It looks just like an overdose. My partner starts providing care to the patient.
I turn to the wife.
Me: “Can you please show me the medications he’s taking?”
Among other things, he has been taking a sedative. I immediately pour them out on the kitchen table and count them. I look at the bottle and see that it is a new prescription. There are only one or two pills missing. I gather all the pill bottles into a bag and hand it to the wife.
Me: “Please bring this bag with you to the hospital.”
We transport the patient to the hospital. About fifteen minutes after that, something in my brain pops. I am familiar with the pills that the man is taking, as this isn’t the first time I’ve had to dump and count the pills in a bottle. Something about them was not right. The typical dosage is 0.25 mg or 0.5 mg. His pills seemed bigger than any others I had ever counted.
Never have I called a patient or family after transport, but today, I do. I call the wife.
Me: “[Wife], can you please pull the bottle of [sedative] out of the bag and read off the dosage size for me?”
It’s a full 2.0 mg!
Wife: “My husband’s regular doctor has been out of town, so he went to the covering physician, who gave him the prescription.”
Me: “What is his regular dosage?”
Wife: “It should have been 0.25 mg.”
Her husband received an overdose of eight times his usual dosage! I told her to report this information to the emergency room.
Yes, errors are made sometimes. But there are many checks and balances in medicine. One of the biggest ones is when a pharmacist reviews a medication and dosage for appropriateness. In this case, the doctor made a huge error in prescribing the wrong dosage. But the pharmacist should have caught it and clarified with the doctor before filling the prescription. Not doing so could have killed the husband.
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