A 3-month-old was admitted to the hospital after the ventricular septal defect was diagnosed. She is in the early stages of congestive heart failure and digoxin is indicated. After discussing the proper dose with the colleague, the drug is administered.

After thirty minutes, the baby vomited which was followed by a cardiac arrest and lastly, the baby died. In writing the attending physician misplaced the decimal point in prescription which eventually led to 10 times greater dose of digoxin.