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Case Study Concerns An Infant That Died Due To The Wrong Medication Treat

1482 words - 6 pages

In sum,( Roberta Carroll’s , Risk Management Handbook for Health care Organizations), Case study concerns an infant who was prescribed a medication to treat congenital syphilis that was transmitted from the infant’s mother.( Roberta Carroll,2009) “The hospital did not have a complete medical history from the mother. A dosage of benezathine pen g 150,000 IM was written to be administered to the infant. All of the health professionals involved were unfamiliar with the medication and treatment procedures of this kind. The pharmacist, not knowing this particular drug, further investigated the notes from the doctor who prescribed the treatment. He also looked up the facts about the drug to be able to determine a dosage for the infant. In trying to determine the correct dosage, the pharmacist misread the usual dose given to adults as 500,000 units /kg. If the correct dose was read, it should have been 50,000 units /kg. There was no procedure in place for rechecking the prescribed dose to the infant, therefore the mistake was not detected”. (Roberta Carroll, 2009)
“The medication was put into a plastic bag containing two full syringes of permapen 1.2 million units /2ml each with stickers to note the dosage strength”. Roberta Carroll, 2009). The label indicated that 2.5 ml of the medication is to be administered IM to meet the dose of 1,500,000 units.”(Roberta Carroll, 2009) Then the primary care nurse became concerned when she saw the amount of injections the infant was supposed to receive in order to give the baby the dose prescribed. She was concerned because 0.5 ml is the maximum an infant is allowed to receive intramuscularly. (Roberta Carroll, 2009) She decided to consult two of the advanced level nurses. One of the nurse’s she consulted was a neonatal nurse practitioner and the other was an advanced level nursery nurse. In not knowing what to do they decided to look up the medication to see if it could be administered through IV. The nurses did so by looking into Neofax and putting in the medication there was no mention that it could or could not be administered through IV.

PORTFOLIO PROJEC Being they were not familiar with this particular medication they assumed that the medicine could be administered through the IV method. . (Roberta Carroll, 2009)
Due to the primary nurse not having the proper certification for her to administer an IV to the infant, the responsibility of giving the medication became the advanced level nursery nurse responsibility. While preparing to administer the drug to the infant there was a label on the medication that said only IM use, but the nurse failed to notice the warning. Due to the fact that the warning was not prominently placed on the medication, it was not seen by the advanced level nursery nurse. The dose of medication of 1.8 ml was given to the infant, soon after the infant was unresponsive. They attempted to resuscitate the infant but the baby was not responding, and...

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