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August 9th, 2017 
admin Risk Management
Paper instructions:
This paper should be regarding the attached case study.
A risk manager’s role in addressing the events described in the case studyThe Joint Commission requirements for reporting sentinel events for a hospital
Steps a risk manager must take to address these events
Processes and techniques that a risk manager would take to investigate, prevent, and control these types of events now and in the future
Internal and external individuals and entities that might be involved in this situation, why, and in what capacity
The practicality and implications of one or more theories on accident causation
Measures to assess the performance of the organization and the risk management plan in this area as it relates to patient care and compliance
Impact these events could have on organizational performance, compliance, and accreditation
1
HCM370 Quality and Risk Management in Health Care Organizations
Portfolio Project Case Study
An infant was born to a mother with a prior
history of syphilis. Despite having incomplete
patient information about the mother’s past
treatment for syphilis and current medical
status of both mother and child, a decision was
made to treat the infant for congenital syphilis .
After consultation with infectious disease
specialists and the health department, an order
was written for one dose of “Benzathine Pen
(penicillin) G 150,000U IM.”
The physicians, nurses, and
pharmacists, unfamiliar with the treatment of
congenital syphilis, also had limited knowledge
about this drug, which as not in their formulary.
The pharmacist consulted both the infant’s
progress notes and Drug Facts and Comparisons
to determine the usual does of penicillin G
benzathine for an infant. However, she misread
the dose in both sources as 500,000 units/kg, a
typical adult dose, instead of 50,000 units/kg.
Due to lack of a pharmacy procedure for
independent double checking , the error was not
detected. Because a unit dose system was not
used in the nursery, the pharmacy dispensed a
tenfold overdose in a plastic bag containing two
full syringes of Permapen 1.2 million units/2mL
each , with green stickers on the plungers
reminding the provider to “note dosage
strength.” A pharmacy label on the bag
indicated that the 2.5 mL of medication was to
be administered IM, to equal a dose of
1,500,000 units.
After glancing at the medication, the
infant’s primary care nurse was concerned
about the number of injections it would be
necessary to give. (Because 0.5 mL is the
maximum that providers are allowed to
administer intramuscularly to an infant, a
1,500,000?unit does would require five
injections.) Anxious to prevent unnecessary
pain to the infant, the nurse involved two
advanced ?level colleagues, a neonatal nurse
practitioner and an advanced ?level nursery
nurse, who decided to investigate the possibility
of administering the medication IV instead of
IM.
NeoFax was consulted to determine if
penicillin B benzathine could be administered
IV. The NeoFax monograph on penicillin G did
not specifically mention penicillin G benzathine;
instead, it described the treatment for
congenital syphilis with aqueous crystalline
penicillin G, IV slow push, penicillin G procaine
IM. Nowhere in the two ?page monograph was
penicillin G benzathine mentioned, and no
specific warnings that penicillin G procaine and
penicillin G benzathine were to be given “IM
only” were present.
Unfamiliar with the various forms of
penicillin G, the nurse practitioner believed that
“benzathine” was a brand name for penicillin G.
This misconception was reinforced by the
physician’s method of writing the drug order,
written with “benzathine” capitalized and
placed on a line above “penicillin G” rather than
after it on the same line (See Figure 7.1). It is
noteworthy that many text use ambiguous
synonyms when referring to various forms of
penicillin . For example, penicillin G benzathine
is frequently mentioned near, or directly
2
associated with, terms “crystalline penicillin”
and “aqueous suspension.” Believing that
aqueous crystalline penicillin G and penicillin G
benzathine were the same drug , the nurse
practitioner concluded that the drug could
safely be administered IV. While the nurse
practitioner had be taught in school that only
clear liquids could be injected IV, she had
learned through practical experience that
certain milky white substances, such as IV lipids
and other lipid ?based drug products, can indeed
be given IV. Therefore, she did not recognize the
problem of giving penicillin G benzathine, a
milky white substance, through an IV.
Complicating matters further in this
example, hospital policies and practices did not
clearly define the prescriptive authority for
nonphysicians . Partly as a result of this lack of
clarity, the neonatal nurse practitioner assumed
that she was operating under a national
protocol, which allowed neonatal nurse
practitioners to plan, direct, implement, and
change drug therapy. Consequently, the nurse
practitioner made a decision to administer the
drug IV . The primary care nurse, who was not
certified to administer IV medication to infants,
transferred care of the infant to the advanced ?
level nursery RN and the nurse practitioner.
As they prepared for drug
administration, neither of these providers
noticed the tenfold overdose or that the syringe
was labeled by the manufacturer “IM use only.”
The manufacturer’s warning was not
prominently placed. The syringe needed to be
rotated 180 degrees away from the name
before the warning could be seen. The nurse
began to administer the first syringe of
Permapen slow IV push . After about 1.8 mL was
administered, the infant became unresponsive,
and resuscitation efforts were unsuccessful.
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