Risk in Treating Infant Syphilis
An infant was born to a mother with a prior history of syphilis; decision was made to treat the infant from congenital syphilis. Order was written for one dose of "Benzathine Pen (penicillin G150, 000U IM". Physicians, nurses, and pharmacist unfamiliar with the treatment, Pharmacist misread the dose in both sources as 500,000 u