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Is the Nurse Incompetent?
The Health Care Blog

        This case is prompting a lot of comments, some of them taking issue with the concept of systemic failures and instead asserting that the young nurse was clearly incompetent, in that her error was inexplicable. So, let’s turn from a clinic in Brazil to a recent case in a hospital in the US, cited in this article on AHRQ’s Web M&M. A summary: The order was written correctly in the electronic medical record (EMR) for phenytoin, 800 mg IV. The drug-dispensing machines stocked phenytoin in 250 mg/1 mL vials.