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.
What went wrong in this scenario?
What can be done to prevent this type of sentinel event from occurring? Provide specific examples
Sentinel events are a patient safety event that results in death, permanent harm, or severe
temporary harm. Sentinel events are debilitating to both patients and health care providers
involved in the event. In this scenario, things that resulted in the patient's death included
treatment being administered to the infant prior to test results being made available, the order
being improperly read by the pharmacy, and the clinical staff administered an IV route to the
infant rather than the route that was originally assigned. This could have been prevented if the
staff paid attention to detail and instead of rushing patient care took the time to access the
proper treatment plan. If fear of the mother and child not returning, staff should have involved
the proper authority such as CPS.
