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/2 mL were dispensed with directions to administer 2.5 mL 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.

Answer 1

This is an sentinel event ,where the nurses and the hospital are liable for the child's death.

Misinterpretation is a form of medical malpractice by the pharmacist and issuing a wrong dosage without counter verifying is liable

The act of the nurse is highly responsible for the event, in these types of situations doubts has to be clarified with a senior staff or with a supervisor. In case no help is available it is better to call the pediatrician and get knowledge regarding the route of administration.

Penicillin is a drug which has to be given only by Intramuscular injection only,an administration via intravenous route is dangerous to life and can result in death.Hence making wave to claim for a wrongful death lawsuit.

The mistakes or malpractice done by a staff ,directly affects the management and they are responsible for it.They should have formulated a better protocol and policy from preventing it.