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.

Scenario 2: Mivacurium (Mivacron), instead of metronidazole, was accidentally administered to several patients at a large hospital. Three patients went into respiratory arrest, and one died. A multidisciplinary team was assembled to analyze the event and determine actions that could be taken to prevent similar errors from recurring. Here's what they found: A technician pulled several bags of foil-wrapped IV items from the bulk IV storage area. At the time, it was thought that metronidazole was the only medication in the pharmacy that was packaged in foil outer wraps. However, the anesthesia department had ordered samples of mivacurium from a drug representative without notifying the pharmacy. A shipment of sample products had been delivered to the pharmacy the previous day and placed into stock without notice. The technician placed pharmacy-generated labels that said "metronidazole" on the foil outer wrap of each bag. The pharmacist checked the bags and the computer-generated labels against the physician's order. No one noticed that the foil-wrapped bags actually contained mivacurium. The mivacurium was sent to the nursing unit mislabeled as metronidazole.

When the nurses received the bags, they noted the pharmacy label for metronidazole on the outer foil wrap. They verified the drug name on the pharmacy label with the transcribed order on the patient's MAR. The medication was administered IV to four patients, still packaged in the foil outer wrap. All four patients went into respiratory arrest and one died several days later as a result of the error. The incident resulted in the termination of a pharmacist and a pharmacy technician and the suspension of several nurses.

• what went wrong in the two situations
• what steps might the healthcare organization take to prevent future instances
• what policies/procedures should be implemented based on this analysis.

Answer rating: 100% (QA)

In both situations several critical errors occurred leading to tragic outcomes 1 Penicillin G Benzathine Administration The initial order was misinterpreted by the pharmacy resulting in a tenfold over... View the full answer