Problem: 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:
1) The practicality and implications of one or more theories on accident causation
2) Measures to assess the performance of the organization and the risk management plan in this area as it relates to patient care and compliance.