Abstract
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.
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