A patient received phenobarbital 0.5 grams (500 mg, obtained from 4 x 130 mg unit dose syringes) IV daily for three days instead of 0.5 grains after the prescriber misread the apothecary dose listed on the patient's prescription bottle http://www.ismp.org/MSAarticles/A3Q99Action.html
Plain text posting preferred. -- Terry Simpson Human Factors Consultant [EMAIL PROTECTED] www.connected-systems.com Phone: +44 7850 511794 -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Matthew Zotter Sent: 14 September 2003 20:54 To: U.S. Metric Association Subject: [USMA:26967] famous blunders 2003 SEP 14 SUN What are all of the famous blunders resulting from people not using the metric system? I know of: 1983 July 23, a Boeing 767, Air Canada Flight 143 known ever since as the Gimli Glider, ran out of fuel over western Ontario because of confusion between kilograms and pounds. 1999 September 23, Mars Climate Orbiter crashes into Mars. One design team used English units while the other used metric units for maneuvers placing the spacecraft into a proper Mars orbit. What others are there? Thank you for your time and attention. Sincerely, Matthew Zotter
