An Unintentional Overdose: A Case Report

The error prone processes of prescribing and administering medications is made even more dangerous when uncommon and potentially lethal medications are involved. This case report describes the admission of a patient who suffered an in-hospital theophylline overdose’s subsequent critical care admission and resultant death. Included is a review of the most prevalent and recent evidence regarding this type of toxicity including extracorporeal removal and multidose activated charcoal as well as a reflection of how this multi-faceted fatal error occurred.