A nurse transmitted a physician's order for 1 gram of Ativan directly to the pharmacy without recognizing it as an error.

“which again any pharmacist with any experience would recognize that's a supraphysiologic dose that would be enough to kill an entire i don't know enough a stadium of people but again the pharmacist was also brand new it was a night shift maybe putting the new person on at the night shift when there's less action so the pharmacist sent up all of the ativan that he had in the system which was tens of milligrams and said look i'll get the rest later i have to reach out to another hospital to get it but you know whatever it was here's 20 or 30 milligrams of ativan and i'll get the other 970 milligrams later”