TEAMWORK IS NOT AN ABSTRACT IDEA In 2010, Alameda County Medical Center was fined $75,000 by the California Department of Public Health (DPH) for a preventable medication error which resulted in a patient's death. The patient, a female with end-stage renal disease requiring thrice-weekly hemodialysis, was admitted to the hospital for sudden shortness of breath and chest pain. During a dialysis session two days after admission, she experienced seizures, hypertension, and acute pulmonary edema necessitating transfer to the ICU. At 1400, shortly before transfer to the ICU her attending physician ordered 1000 mg phenytoin IV over 1 hour (specifically mentioning that the dose should not be "pushed quickly"). According to hospital records, the order was scanned to the pharmacy 45 minutes later. Because IV phenytoin was in the ICU's Pyxis unit, the pharmacy assumed the dose had already been given and took no action on the order. Approximately 7
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