A 51-year-old female patient with Guillain-Batré syndrome was given three times the intended dose of intravenous human immunoglobulin while admitted to a tertiary intensive care unit. The error went unnoticed for seven hours and appears to have been the result of several successive breakdowns in communication between key staff. The patient, fortunately, made a full recovery.
This report analyses the communication failure and explores possible ways of avoiding similar occurrences in the future.
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