Decimal point kills baby?

“The mistake made by the nurses was a mathematical miscalculation which in other working environments might not have been quite so catastrophic”

The quote is from the coroner in a case of a 15 day old baby given 10 times the prescribed dose of Digoxin to slow a fast heart rate and appears on the BBC News report of the case. The two nurses who gave the drug “told the hearing they checked and double-checked the drug levels before administering the injection to baby George”. One of the nurses continued [ my italics ]

“Because we had calculated it both separately and together and checked it to make sure it was accurate to the book, we believed that we were giving the right dose….. If we had any doubt whatsoever we would not have given the dose.”

Is this about mathematics or about knowing what the ‘rough ballpark’ dose is for drugs used at various stages of a baby’s development. Is it numeracy or contextual knowledge?

The full BBC News article also mentions comments about work loads on the ward at the time, and changes in procedures that will lead to more definite dosages being checked by pharmacists.

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