Learning from adverse events

​Earlier this year I was involved in the resuscitation of a child who suffered a cardiac arrest in our department. She had inadvertently received an overdose of phenytoin after being intubated for status epilepticus.

A whole team of dedicated professional staff were looking after her, and every member of that team was working hard to give her the best possible care. Despite this, she still received the incorrect dose of phenytoin. This post is intended to share learning and encourage staff to reflect on the human factors which contributed to this serious incident. Please read it carefully and consider how, despite best intentions, errors can easily occur, particularly during stressful and rare clinical scenarios.

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