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JAMA 100 Years Ago
October 9, 2002


Author Affiliations

JAMA 100 Years Ago Section Editor: Jennifer Reiling, Assistant Editor.

JAMA. 2002;288(14):1788. doi:10.1001/jama.288.14.1788

A recent unfortunate occurrence of the death of a patient in a well-known hospital from an overdose of strychnin calls for some comment. It reveals a very bad practice—which we trust is unique—of leaving the making up of solutions of powerful drugs in the hands of undergraduate nurses, and the presumption, to call it no worse, of a superior nurse who, with or without the connivance of the pharmacist, introduced the use of one-grain tablets for the purpose of making up such solutions. Another very bad feature of the case is the attempt to lay all the blame on the undergraduate nurse who administered the fatal dose, under the not unnatural supposition, under the circumstances, that she was giving the ordinary tablet dose. What business a hospital could have with one-grain tablets of strychnin is hard to appreciate, and the practice followed by the responsible parties is as reprehensible as their conduct in regard to the young woman was objectionable. The blighting of her career for an error, serious as it was in its results, for which others who go uncensured were primarily responsible, is inexcusable. The case illustrates the lack of proper appreciation of their functions on the part of some who are too ready to take on responsibilities that in no wise belong to them, as in thus ordering the one-grain strychnin tablets, and then to put off the consequences of their misdoings on comparatively untrained and irresponsible subordinates. The censure of the administration of the hospital by the coroner's jury seems well deserved, and we trust its medical staff will succeed in promptly securing the reforms they are demanding.

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