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A Little Dot Can Kill You

Think of the tiny things in our lives: Lilliputians in “Gulliver’s Travels,” the famous, but indeed very old Brill-cream slogan “A little dab will do you!” How about mini-bars of Snickers or Mounds candies?


“Good things come in small packages!” Your beloved, down on one knee, presenting the little box housing the treasured engagement ring. It doesn’t get much better than that! How about the famous little blue packages from Tiffany’s? Little can be wonderful.

A little “dot” however, is an entirely different matter.

Hubby was vomiting violently a few years ago and we rushed him to the Emergency Room at our favorite hospital. While he was waiting to be “triaged” to determine the problem, the E.R. doctor assigned to his case asked me which medications Hubby takes daily. When I showed him the list, his ever-so eloquent auto-response with no filter was “Shit!.” Eighteen pills in a day made it a tremendous challenge for the doctor to resolve Hubby’s problem which could have any of a number of root causes. This same doctor asked me to come with him to the computer while he recorded Hubby’s medications to be administered daily, once actually admitted to the hospital. I had the list with me. I handed it to him and waited as he recorded the complicated selection. The hospital often does not have every medication needed, and as such I was asked to provide the missing doses from our stock at home. (One additional note to consider: If a patient spends the day in the Emergency room prior to being assigned a room, they will probably not receive any of their medications during that day. Family needs to be clear as to what needs to be brought from home immediately – just to get through the day in the E.R. without adding additional problems.)

Hubby was finally admitted, situated in his room, and received his medications from the hospital’s pharmacy-trained-pill-dispensing nurse on day two. A few hours after taking the medications, he tried with great difficulty to lift himself off his bed and he fell on the floor, in a stupor. No one understood why he was suddenly so weak. He was definitely in worse condition than when he had arrived in the E.R., the day before.

The following day (day 3), a different, lovely young nurse in charge of administering the patients’ medications on that shift, asked me “Is it possible that your husband takes 15 mg. of Cardiloc each day?” “Of course not! I responded vehemently. He takes 1.5 mg of Cardiloc. I too am on the same dosage. I recall that our cardiologist started me on 2.5 mg and that I felt as if I had been “hit by a Mack truck”. I could barely sit up in bed from its impact on my heart. How could anyone even consider giving a patient 15 mg? But that is exactly what had happened the previous day. Not only had the E.R. doctor entered the decimal point in the wrong place, which alone would have been bad enough. But then, the pharmacy nurse actually administered this massive amount without even noticing it was an unusually high dosage. It should have been fatal.

When the head of the department (for whom we had paid extra to monitor Hubby’s case) sat with us and we complained about the error – his response was: “The good news”- is that your husband’s years of working out in the gym, have given him such a strong constitution that he survived the overdose. That was very little consolation. And if he had he not?

The bottom line, and what I want to share with anyone who will listen is that human error not only happens, it happens frequently. When your loved one is admitted to a hospital, ask to see the computer medication list as soon as it is entered. Errors can be caught and corrected, but vigilance is not only the order of the day. It is critical. Our old attitude, that we trust our medical teams to be infallible is so foolish and so dangerous. We experienced not one error but two – back-to-back. There was no excuse for either. My meeting with the head doctor in charge of the Emergency Room put the offending doctor on notice. Another such error would not be tolerated so lightly. I would hope it would not be tolerated at all.

Once one has experienced errors such as these, there is no option but to take a different approach when tending to a hospitalized loved one. Ask questions. Be pro-active. Demand attention (albeit nicely) when it is required. Try not to leave your patient alone…ever. It is likely that they cannot manage on their own, and in instances where they are offered the “magic button” to press when they need assistance, be sure that your loved one is actually capable of remembering that there is such a button! This applies to all patients of course, but those suffering from short-term memory loss will not remember anything that they are told. They will be confused and frightened.

For patients with memory-loss, it is especially critical that a family member is with the patient when the doctors make their rounds. When the doctors interview the patient, it is important that they receive the correct answers to their questions. The doctors may not be aware that someone, such as Hubby, will be unable to recall his different medical issues and history. In our case, he certainly did not remember any of his prior surgeries, allergies, or conditions. Misinformation shared by a patient to a doctor, is a potential mine-field for mistaken conclusions and further disasters.

We have a dear friend whose husband is in a late stage of Dementia. She tells me that she handles the stress by telling herself that her Hubby is a little child. One has no expectations that a small child will be able to fend for themselves. Having that approach when caring for a loved one with any form of Dementia, is helpful. It removes normal “expectations” that we have had and replaces them with a realization that everything depends on the responsible care-giver. The patient can no longer help themselves, and thus, we must do it in their stead.

The idea that a misplaced “dot” in a computer, when a prescription dose is entered, could kill you is not something that most of us would ever “dream” could happen. No doubt, the doctor who recorded the dose, the nurse that administered it, and the hospital would apologize profusely if the patient died. How absurd and totally worthless would that be? Forewarned, is hopefully forearmed.

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Barbara Diamond is a journalist living in Jerusalem, Israel. She has been a political activist on behalf of Israel and the Jewish people for over fifty years, having participated in political and humanitarian missions to Ethiopia, the former Soviet Union, China, and Europe to meet with world leaders on matters of concern. She has written over 100 articles for the Jerusalem Post and on her blog at The Times of Israel, hosted an English radio talk show in Jerusalem and continues mentoring others to pass on the torch of responsibility. You can reach her at [email protected] and visit her site at