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UNIT TWO ASSIGNMENTS
Unit Two Case Analysis
CASE STUDY 7.1
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 the 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 was not in their formulary.
The pharmacist consulted both the infant’s progress notes and Drug Facts and
Comparisons2 to determine the usual dose 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 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 dose would require five injections.) Anxious to prevent any 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.
NeoFax3 was consulted to determine if penicillin G benzathine could be administered
IV. The NeoFax monograph on penicillin G did not specifi cally mention penicillin G
benzathine; instead it described the treatment for congenital syphilis with aqueous
crystalline penicillin G, IV slow push, or penicillin G procaine IM. Nowhere in the twopage monograph was penicillin G benzathine mentioned, and no specifi c 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 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. Read case study 7.1. Write a 5 Page paper (at least 1500 words) in APA format addressing the following:
How did the presence of incomplete patient information drive the story contained within the
study?
How did the interaction between the pharmacy and nurse practitioner reinforce the mistakes
leading up to the death of the infant?
How could have the manufacturer of the drug interact with or train hospital personnel
regarding the product?
Where, in the chain of individuals handling the drug, would you recommend checks as to
ensure the proper administration of the drug? Why?
Below is a recommended outline.
1. Cover Page (See APA Sample paper) 2. Introduction
a. A thesis statement
b. Purpose of paper
c. Overview of paper
3. Body
4. Conclusion – Summary of main points
a. Lessons Learned and Recommendations
5. References – List the references you cited in the text of your paper according to APA format.
(Note: Do not include references that are not cited in the text of your paper)
Attachments: