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A 58-year-old housewife recently died in a Tokyo hospital following surgery for rheumatism in her left middle finger. After receiving an IV, the woman began complaining of chest pain and died less than two hours later. An internal investigation revealed that a nurse had mistakenly infused 10 ml of the disinfectant hibitane gluconate into the woman’s IV.
The patient’s attending physician had originally prescribed 100 ml of an antibiotic and 10 ml of an anticoagulant. The nurse who prepared the IV was not the same nurse who administered the dose to the patient. Further investigation is impossible because the patient’s body was cremated.