A young man, Pablo Garcia, visited the hospital for a standard course of treatment to address a terrible condition. The night he went to the hospital, he experienced many unusual symptoms. His body was riddled with numbness and tingling, and as time progressed, his condition appeared to worsen. Throughout his life, he had suffered from a dangerous genetic condition known as NEMO syndrome, which induces infections and bowel inflammation over the course of a lifetime.

When he was initially admitted to the hospital, he was assessed for a polyp in his bowel area. He was given a standard colonoscopy at the University of California, San Francisco Medical Center’s Benioff Children’s Hospital. However, after this simple procedure, the unthinkable happened.

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Pablo Garcia’s Health Took a Turn for the Worst

At approximately 9:00 p.m., he consumed his medication as directed, which included a course of steroids and antibiotics to treat any existing infection. But as his symptoms intensified, he confided in his nurse about the fear of his declining health.

So, she wondered if one of two factors were to blame for his worsening condition. Were his symptoms being caused by the bowel cleaning solution he consumed, or by his anti-nausea pills? The nurse could not explain this medical mystery, so she summoned the aid of the physician on call that night. The physician accessed Pablo’s online medical records for an exhaustive list of medications. Perhaps this would shed insight on the situation.

An Accidental Overdose

hqdefaultFlabbergasted, the doctor revealed an alarming discovery. Rather than prescribing the patient with a standard dose of Septra, an antibiotic, Pablo had received approximately thirty-eight of those pills. This antibiotic, which treats urinary and skin infections, now flooded his body and dampened his hopes of recovery.

The nurse admitted that she inadvertently had given him this unnervingly large dose of medication. Frenetically, the doctor phoned toxicology experts at the Center for Poison Control, and even they were astounded by this revelation. Never once had they documented an accidental overdose of this magnitude. Their only available recourse was to monitor him as closely as possible and hope for the best.

His family prayed anxiously as the rapid response team flooded his room. Suddenly, Pablo began to have a grand mal seizure and his respiration stopped as the Code Blue Team arrived.

When the Rube Goldberg system was in place, computerized prescriptions and medical records were nonexistent. Hospitals relied on paper records, which required manual calculations and entries of the patient’s data. Although computerized patient systems have systematized the medical industry, it failed in this capacity. Using weight-based calculations, this computer system calculated his dosage to be thirty-eight pills, in accordance with his weight. Hence, this is a tale of caution not to be ignored. Medical technology has a long way to go.