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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