The Cleveland Plain Dealer   National  A9   2001-08-01
 
A mathematical error may have caused the deaths of two hospital patients who were given the wrong amount of blood-thinning drug, the hospital said yesterday.  Officials at St. Agnes Medical Centre in South Philadelphia said they made a mistake in an equation to determine the lab test results for 932 patients between 04 June and 25 July.  The test was suppose to determine the proper dosage they receive of Coumadin, a common blood thinning drug.  both victims were in their mid-80's to mid 90's.  Their names were not released.
 
 
 
 
Hmmm.  Could this "mistake in an equation", have involved either a failure to convert pounds to kilograms or converting with an inverted conversion factor?  Is someone afraid to admit it was a metric error for fear that it might be a catalyst to force the strict use of kilograms in hospitals?
 
Anyone else see this story or hear something about it?
 
 
 
John
 

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