A Massachusetts healthy 76-year-old woman fell and injured herself getting out bed. She developed an infection and went to Massachusetts General Hospital to undergo a course of antibiotics to treat her infection. She died after hemorrhaging for 12 hours while in-patient at the hospital.
The patient was prescribed a blood thinner called Lepirudin. However, Massachusetts General Hospital employees mistakenly gave her a dose that was 30 times higher than recommended. This made her body incapable of clotting her blood. When she began bleeding internally, the bleeding would not stop and she died. The hospital released an apologetic statement, saying there would be an internal review and the development of new hospital policies. One possible plan included a new system of reviewing and approving dose infusions. The hospital openly took the blame for the mistake and indicated the situation could have been prevented if employees had been more careful.
According to the Boston Globe, dosage errors have been the single leading cause of fatal medication mistakes for a long time. In 1994 Boston Globe health columnist Betsey Lehman died due to a chemotherapy drug overdose. That tragedy sparked a national movement toward the prevention of similar errors by hospitals. Hospitals continue to attempt to enact policies and practices that avoid such tragedies.
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