Reporting Incidents

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.
Submit your summary and tool.
Point Allocation
Comprehensiveness of Case Study Summary
15 points
Who should be responsible for reporting incident, Explain based upon course information
15 points
Detailed Explanation of why person was Responsible for Death Analysis
20 points
Detailed Explanation of how the incident happen
20 points
Detailed Description of how to prevent future incidents based on course information
25 points
Reference at least two references in APA format.
5 points
Total
100 points

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