In April 2011, we lost a colleague to her own hand ostensibly because she committed a medication error. Kim Hiatt was a critical care pediatric nurse at Seattle Children's Hospital when, in September 2010, she gave 1.4 g of calcium chloride to a child who was supposed to receive 140 mg of that drug. The dreaded and, sadly, often repeated decimal point error can occur far too easily when nurses are required to perform calculations during critical situations to draw up and administer medications to our most vulnerable patients, children.
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