Question

An attending physician ordered the administration of 50,000 units/kg of penicillin G/benzathine intramuscularly to a full-term infant. Baby Sandy. Ms. Erin Smith, a registered nurse assigned to care for the infant, sent the order to the pharmacy and subsequently received two syringes of penicillin G/benzathine from the pharmacy

            The two syringes contained a total medication volume of 2.5 ml. The unit’s policy concerning infant intramuscular injections allowed for a maximum medication volume of 0.5 ml per injection. After receiving the two syringes of medication, Nurse Smith commented briefly to her unit colleagues about the number of times she would be required to stick the infant. She then began her other unit activities before returning to administer the injections to Baby Sandy.

            On Nurse Smith’s return to attend to Baby Sandy, Nurse Smith noticed that Ms. Marcy Davis, the unit’s nurse practitioner, and Ms. Margo Johnson, a registered nurse also working in the unit that day, were researching information about penicillin and the injections that were to be administered to Baby Sandy. Their joint goal was to decrease or climate the need for Baby Sandy to receive multiple intramuscular injections.

            Before filling and dispensing Baby Sandy’s penicillin G/benzathine, the hospital pharmacist called the nursing unit to obtain the infant’s weight. However, unknown to Nurse Smith, Nurse Davis, and Nurse Johnson, the pharmacist misinterpreted the order. He prepared 500,000 units of the penicillin per kg of the infant’s weight instead of the ordered 50,000 units per kg.

            The pharmacist did correctly note that penicillin G/benzathine was a viscous solution and therefore labeled the two syringes of penicillin G/benzathine as “IM USE ONLY” before dispensing the penicillin G/benzathine to the nursing unit.

            While Nurse Smith was attending to her other nursing activities, Nurse Johnson consulted with Nurse Davis to see if the medication could be administered intravenously, thus negating the need for injecting the baby through multiple intramuscular injections.

            Nurse Davis and Nurse Johnson consulted two drug references for “penicillin G” in one reference and “penicillin G potassium/penicillin G sodium” in another. Both of the references for these medications indicated that the penicillin could be administered intravenously. Nurse Davis informed Nurse Smith that both Nurse Davis and Nurse Johnson would administer the penicillin to the infant.

            Nurse Davis changed the physician’s order for the route of the penicillin administration from intramuscular to intravenous. Nurse Johnson started the infant’s IV and intravenously administered the penicillin G/benzathine to the infant. Baby Sandy expired.

Identify the issues and error(s). Next identify the cause of the issues and error(s) and suggest how the error(s) could have been avoided.

Answer 1

ISSUES AND ERRORS IN THE ABOVE SCENARIO IS :

* Ms.Smith even after receiving the medicine from pharmacy, instead of checking it she got involved into other works.

* Ms. David and Ms. Johnson unnecessarily involved in Ms.Smith's work without knowing anything about the patient.

* Ms.Davis and Ms. Johnson didn't do the drug references clearly.

* All the three nurses didn't check the physicians order clearly.

* Misinterpretation of the order

* Changing the physicians order by Ms. Smith was another error.

* Inspite the pharmacist labelled in the syringe that only for IM use, they gave it intavenously.

* Intravenous administration of Penicillin G is another big error

CAUSES OF THE ISSUES AND ERRORS CAN BE DUE TO:

* Lack of proper knowledge about the drugs and its way of administration.

* Failure to check the order clearly before telling the pharmacist and before administering the drug.

* Misinterpretation of order is another cause

* Ms. Smith got involved in other works, even after receiving the medicine which made the other two nurses to take up her work.

* Changing the order written by the physicians

* Carelessness of the Nurses

* The didn't follow the rights of medication administration.

HOW TO AVOID THESE ERRORS:. These errors could have been avoided if they would have followed the rights of medication administration.

Ms. Smith as soon as she received the medicine from pharmacy inspite of involving in other works she should have checked the medicine.

Proper checking before administering the medicine could have avoided he error.

They should not have changed the Physicians order which they are not supposed to do. Only doctors have the right to write or change orders.

They should have been careful enough to atleast see the label in the syringe which is mentioned as Only for IM use.

They should not have started an IV line and administer the medicine without informing the Physician.