Question

A newborn infant died after receiving penicillin G benzathine IV. An order for penicillin G benzathine 150,000 units was written for the infant after it was discovered that the mother had contracted syphilis while residing in another state. Laboratory tests were also ordered, but a decision to treat the infant before results were available was made due to a fear that the mother may not return with the infant for follow-up treatment. The order was misinterpreted by pharmacy at 1.5 million units. Subsequently, two prefilled syringes of 1.2 million units/2mL were dispensed with directions to administer 2.5mL of the drug by the IM route. Due to the volume that would have to be administered to the infant, two nurses investigated if the medication could be given intravenously. After misinterpreting information about the drug in reference texts and via oral communication with the Department of Health, the medication was administered by the IV route, which ultimately caused the infant’s death. In a 2-page summary: Who do you feel is responsible for the death of the infant? What if any can be done to prevent this incident from occurring in the future? How did this incident happen? Who should be responsible for reporting the incident? Explain. Develop an incident reporting tool that could help in evaluating this case.

Answer 1

Firstly, the pharmacy is is responsible for the death of the infant because they have misinterpreted 150,000units as 1500000 units and dispensed wrong vials . Secondly ,the nurse is responsible for the death of the infant because they haven't followed the 6R's properly and haven't checked the dose of the available medicine .

To prevent this incident from occurring in the future the healthcare organisations must take strict legal actions towards the pharmacy and nurses so that it is a lesson for other healthcare workers to be vigilant while dealing with patients. Also implementation of strict adherence to the hospital protocols of medication administration and prevention of negligence and malpractice .

This incident happened because pharmacy misinterpreted 150,000units as 1500000 units and dispensed wrong vials . Secondly ,the nurse haven't followed the 6R's properly and haven't checked the dose of the available medicine .

The nurse is responsible for reporting the incident because they have administered the wrong dose of medication to the infant and it resulted in death of the infant .