Denver Nurses Analysis

     Just as the “Monday Morning” quarterback would have recognized dangers and grabbed opportunities while leading the team to certain victory, we second-guess adverse events without fully understanding the complexity of the situation. When we know the outcome of a situation, we are much more likely to judge the process as inadequate, substandard, or less than perfect when the outcome is negative than when positive. The correct action that should have occurred is crystal clear. Hindsight is 20-20.

A combination of latent failures occurring simultaneously created the conditions for the accidental death:

• Post-partum nurse is busy so the other two nurses (neonatal nurse and neonatal nurse practitioner) offer to help. No RN checked the dose.
• The nurse practitioner thought the dosage was within the scope: Max dose IM = 0.5 ml; Infant was given 1,500,000.
• Pharmacist misread dose as 1,500,000u/kg instead of 150,000u. 2nd pharmacist “confirms” dose.
• The RN thought “Benz” was a brand name for Penicillin. She did not have adequate information from the pharmacy about the drug and no warning labels that it could be administered IM only.

A language barrier led to the decision to treat the patient’s baby as an inpatient in order to make sure treatment was carried out as prescribed.