A 3-month-old was admitted to the hospital after a ventricular septal defect was diagnosed. She was in the early stages of congestive heart failure, and digoxin was indicated. The drug was administered after discussing the proper dose with colleagues. After thirty minutes, the baby vomited, which was followed by a cardiac arrest, and lastly, the baby died. The attending physician misplaced the decimal point when writing the prescription, resulting in a 10 times higher dose of digoxin.
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