On the afternoon that 16-year-old Pablo Garcia was admitted for a routine colonoscopy to the University of California, San Francisco Medical Center’s Benioff Children’s Hospital — an admission that would later be complicated by a grand mal seizure as a result of a 39-fold overdose of a common antibiotic — Benjamin Chan was working in a small satellite pharmacy on the seventh floor, directly adjacent to the wards.
As the pediatric clinical pharmacist, it was Chan’s job to sign off on all medication orders on the pediatric service. The chain of events that led to Pablo’s catastrophic overdose unfolded quickly. The medication orders from Jenny Lucca, Pablo’s admitting physician, reached Chan’s computer screen moments after Lucca had electronically signed them.
Pablo had a rare genetic disease that causes a lifetime of infections and bowel inflammation, and as Chan reviewed the orders, he saw that Lucca had ordered 5 mg/kg of Septra, the antibiotic that Pablo took routinely to keep infections at bay.
Chan immediately noticed a problem with this Septra order: the dose of 193 mg the computer had calculated (based on the teenager’s weight) was 17 percent greater than the standard 160-mg Septra double-strength tablets.
