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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. According to the complaint, 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.

System
Piedmont Healthcare
Facility
Piedmont Rockdale Hospital
Providers involved
Piedmont Healthcare, Inc. / Piedmont Rockdale Hospital, Inc. / Blessing Ngozi Aneke, M.D. / Chinmaya Sharma, M.D. / Samuel Ogbuchi, M.D. / Roni Sharon, M.D.
Pattern
Alleged administration of triple the patient’s usual Dilantin dose despite patient and family warnings
Harm
Alleged severe Dilantin toxicity, neurologic decline, inability to swallow, cardiac arrest, and death

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

  1. According to the complaint, 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.
  2. The complaint alleges that a physician ordered 400 mg of Dilantin three times per day, for a total daily dose of 1200 mg.
  3. According to the complaint, the patient refused several doses and told nurses that he had already taken his daily medication, but staff continued dispensing the higher dose.
  4. The complaint alleges that by November 27, 2024 the patient’s condition had deteriorated with slurred speech and nausea, but the higher dose continued.
  5. The complaint alleges that on November 29, 2024 the medication was changed to intravenous administration because the patient could not swallow.
  6. According to the complaint, 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 that providers failed to perform an appropriate medication reconciliation on admission.
  • The complaint alleges that staff ignored the patient’s and his wife’s warnings that the ordered Dilantin dose was incorrect.
  • The complaint alleges that staff ignored the patient’s refusals of additional doses.
  • The complaint alleges that providers failed to recognize progressive symptoms of Dilantin toxicity.
  • The complaint alleges that 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.

Entities and tags

Piedmont Healthcare, Inc.Piedmont Rockdale Hospital, Inc.Blessing Ngozi Aneke, M.D.Chinmaya Sharma, M.D.Samuel Ogbuchi, M.D.Roni Sharon, M.D.DilantinPhenytoinMedication reconciliationDilantin toxicityCardiac arrestMedication errorFailure to reconcile medicationIgnored patient warningWrongful deathBattery allegationEmergency medicineNeurologyHospital medicinePharmacy safety

Questions this example answers

What does the Piedmont Rockdale Dilantin overdose complaint allege?

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. According to the complaint, 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.

Who is identified in this public case example?

This public case example identifies Piedmont Healthcare, Inc., Piedmont Rockdale Hospital, Inc., Blessing Ngozi Aneke, M.D., Chinmaya Sharma, M.D., Samuel Ogbuchi, M.D., and Roni Sharon, M.D. It also tags the source-supported entities Piedmont Healthcare, Inc., Piedmont Rockdale Hospital, Inc., Blessing Ngozi Aneke, M.D., Chinmaya Sharma, M.D., and Samuel Ogbuchi, M.D.

What alleged failures are summarized here?

The complaint alleges that providers failed to perform an appropriate medication reconciliation on admission. The complaint alleges that staff ignored the patient’s and his wife’s warnings that the ordered Dilantin dose was incorrect. The complaint alleges that staff ignored the patient’s refusals of additional doses.