Piedmont Rockdale complaint alleges fatal Dilantin overdose despite patient warnings
The complaint alleges that a patient at Piedmont Rockdale Hospital was ordered and administered 1200 mg per day of Dilantin, three times his reported usual 400 mg daily dose, despite warnings from the patient and his wife and repeated refusals of extra doses. Staff continued the higher dose while the patient developed slurred speech, nausea, swallowing difficulty, and toxic Dilantin levels, and the patient later suffered cardiac arrest and died.
Overview
This page concerns a public complaint alleging that Piedmont Rockdale Hospital providers administered a fatal overdose of Dilantin after failing to reconcile the patient’s usual anti-seizure medication dose.
Chronology
The complaint alleges as follows:
- The patient arrived at Piedmont Rockdale Hospital’s emergency room on November 24, 2024 for evaluation of numbness and dizziness and reported taking 400 mg of Dilantin daily for epilepsy.
- A physician ordered 400 mg of Dilantin three times per day, for a total daily dose of 1200 mg.
- The patient refused several doses and told nurses that he had already taken his daily medication, but staff continued dispensing the higher dose.
- By November 27, 2024 the patient’s condition had deteriorated with slurred speech and nausea, but the higher dose continued.
- On November 29, 2024 the medication was changed to intravenous administration because the patient could not swallow.
- Blood testing on December 3, 2024 showed a toxic Dilantin level, the medication was discontinued, and the patient suffered cardiac arrest and died on December 6, 2024.
Alleged failures
The complaint alleges the following failures:
- Providers failed to perform an appropriate medication reconciliation on admission.
- Staff ignored the patient’s and his wife’s warnings that the ordered Dilantin dose was incorrect.
- Staff ignored the patient’s refusals of additional doses.
- Providers failed to recognize progressive symptoms of Dilantin toxicity.
- Hospital safety systems should have flagged a dosage exceeding manufacturer limits.
- The complaint asserts a battery theory based on alleged administration of medication after the patient refused it.