Reference no: EM133372910

Question: What went wrong in the two situations below? What steps might the healthcare organization take to prevent future instances, and what policies/procedures should be implemented based on the analysis. Scenario 1: 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