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Syphilis Infant Mismedication Error

A woman with a history of syphilis birthed a child and it was decided that the hospital would treat the baby from congenital syphilis. The prescription was wriiten for one dose of "Benzathine Pen (penicillin G150, 000U IM".

However, the staff attending the mother were unfamiliar with this brand of treatment and therefore did not notice a pharmacist error of sending 500,000 units/kg instead (a typical adult dose, instead of 50,000 units/kg). The nurse unknowingly applied this over-medication and after about 1.8ml was given, the baby became unresponsive.

Explain:

> 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

Solution Preview

There are a variety of theories on accident causation such as: domino theory, human factors theory, accident/incident theory, epidemiological theory, systems theory, combination theory and behavioral theory. Let's examine a few of the theories on accident causation.

The human factors theory states that at the root cause of every accident is caused by human error. The accident is linked to a chain of events of caused by human error. This is a true regardless of the presence of an overload, inappropriate activities or inappropriate response. An overload occurs when an individual's capacity and the load being carried by the individual is in a state of imbalance. An individual's capacity results form a person's training, physical condition, fatigue, natural ability and state of mind. A load is the tasks or activities that an individual us responsible to handle. An individual's load is impacted by additional environmental factors, an individual's internal factors and specific situational factors. In the event of inappropriate responses that lead to an accident, an individual may not be able to detect hazardous conditions, removal of machine safeguards to increase production and not adhering to current safety processes and standards. An individual's workstation may be incompatible because of the difference between the individual and ...

Solution Summary

The prescriptions for Syphilis infant mismedication errors are examined.

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