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Case study

A newborn incorrectly received methylergonovine maleate, a synthetic ergonovine analogue indicated for the management of postpartum atony. What was actually ordered was the hepatitis B vaccine, Engerix-B.
While these two medications do not sound alike, they are similar looking and were stored in the same cabinet in the perinatal area. The infant sustained diminished urinary output for a twelve-hour period and required an additional day of hospitalization for monitoring.

 

critique the following proposed strategy that was based on the case study above, highlighting potential strengths and weaknesses and offering additional suggestions.

 

Proposed strategy: The strategy I would suggest is identify medication to patient strategy.  Staff would have to identify all medication and be knowledgeable of patient medical report prior to administering any meds to the patient. I would not place blame on any one but I would admit error.  I would let the family know what happened, how the child was affected, what steps are being taken to help her, and ensure them that the organization as a whole will take necessary steps to prevent this from happening again. By the patient being a minor, I think the family if they decide to pursue legal action would be well within their rights. Also, if the child has issues or develops permanent side effects once discharged could cause even more issues for the hospital. The hospital may be sued along with staff that was responsible for the error. The hospital could also lose the trust of the patients and its family’s if not corrected.

SCIENCE
HEALTH SCIENCE
NURSING
IHP 315