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.

Read the two scenarios provided here: 

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 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.

Discuss the following:

1.What went wrong in the two situations?

2.What steps might the healthcare organization take to prevent future instances?

As an example, one step for scenario 1 may be to utilize a bedside point-of-care (BPOC) scanning linked to the MAR.

3.What policies/procedures should be implemented based on this analysis?

Note: Identify the policies/procedures that should be implemented based on the analysis of what went wrong and the steps the health care organization should take to avoid future mishaps as described in the scenarios.

As an example for scenario 1, the hospital should implement a policy/procedure that requires switching to the BPOC system and its mandatory use. 

Note: One scenario’s steps and policies/procedures may not apply to the other scenario. Therefore, make sure you are delineating between the two scenarios. Use this as an opportunity to demonstrate your critical thinking skills.

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