A 21 year old woman walked into an emergency room complaining of having taken too much Tylenol for menstrual cramps. An emergency room doctor hooked her up to an IV that delivered a drug called acetylcysteine – the antidote for Tylenol overdose. The ER doctor had never given acetylcysteine by IV before, the emergency room’s pharmacy had never dispensed the drug before, and the nurse who administered the drug had never given the drug before.

As a result, both the pharmacist and the ER doctor made mistakes regarding the amount of medicine the young woman should receive, at what rate it should be given, and over what time period it should be given. But the errors did not stop here. When the medicine got the young woman’s bedside, the nurse did not check to make sure it was correct. At this point, the woman started getting 16 times the recommended dose of antidote. It gets worse.

The young woman was later moved to the hospital’s medical floor. After 21 hours of treatment, the order for the medicine expired, but a nurse called another doctor, and, despite being unfamiliar with both the medicine and the patient, that physician ordered that the drug be continued at the 16 times overdose rate until the next morning.

After a few more hours, the young woman started having seizures. The nurse called a third doctor, who ordered that she be given Haldol. This happened despite hospital rules that required the doctor to visibly assess the patient before prescribing Haldol. The order for Haldol was given over the phone without ever seeing the patient. The young woman eventually started having seizures. By the time the mistakes were discovered, the young woman was brain dead.

North Carolina Lawyers Weekly, who published a story about the case, reported that the woman should have received only 160 milliliters of acetylcysteine, but instead she received at least 6000 milliliters. The pharmacy charged her more than $15,000 for the drug during her 50 hours of treatment. The young woman remains in a persistent vegetative state. The case settled for $15.5 Million. The settlement was confidential.

The import of this case for you should be that no one should ever go to the hospital alone or stay in the hospital alone. You need someone there (a patient advocate) with you to protect you and make sure that mistakes like this do not happen to you. You should always question the medical treatment you are receiving.

Ask questions and demand that the medical provider explain the treatment that is being recommended. If the treatment does not seem to be going well or the patient’s condition does not seem to be improving, then demand that a specialist be brought into the case for the purposes of a consultation. Note well the use of the word “demand.” You can also demand that you be transferred to another hospital if you feel you are not receiving appropriate care. As crazy as it sounds, if you are in a hospital setting, you must take steps to protect yourself.