Denver Nurses Overview

     On October 24, 1996, a pregnant woman arrived at Centura St. Anthony Hospital North near Denver. After her baby boy was born, the staff became aware that the mother had been previously treated for syphilis. A language barrier made it difficult for them to ascertain that treatment had taken place. Although the baby could have been treated at home the consequences resulting from improper treatment for this condition were dire so the decision was made that, although otherwise perfectly healthy, the baby should be treated as an inpatient. In retrospect it was found that the mother’s previous treatment for syphilis had been successful. One child before Miguel and two after were not infected. The need for the ensuing treatment was unlikely but there was no communication between her physician and the hospital staff.

     Because the staff was unfamiliar with the treatment of congenital syphilis, the neonatologist consulted an infectious disease specialist who recommended a lumbar puncture to determine if he was infected along with treatment of a single dose of penicillin G benzathine IM. Another outside expert was also consulted and made the same recommendation. The recommendations were documented in the progress notes section of the physician order form without the designation of "benzathine" or an administration route. The neonatologist documented his order for benzathine the next day. A different neonatologist performed the lumbar puncture but the results would take several days. He wrote the order in an unclear manner, with IM illegibly appearing to be IV.

     The pharmacist was unfamiliar with the drug so consulted the health department and the drug reference book. However, she misread the correct dosage from 500,000units/kg instead of 50,000 units /kg and 1,500,000 units instead of 150,000 units. There was no maximum dose warning in the computerized system and she prepared the incorrect dose in two prefilled syringes with stickers advising that the entire contents should not be administered. Only 0.5 ml can be safely administered to an infant per IM injection. The dose as prepared would require five injections.

     The primary nurse was concerned about the number of injections that Miguel needed. Her colleagues, a skilled nursery nurse and a neonatal nurse practitioner, looked into giving the medication through IV to reduce pain to the infant. The NP thought that benzathine was a brand name for penicillin G. She also thought prescribing this as an IV was under her prescriptive authority. Neither nurse noticed the labels marked "IM use only." The literature did not mention benzathine by name and there were no warnings that it was IM only.

     After he received 1.8 ml of the medication, Miguel became unresponsive and died shortly thereafter. The nurses were indicted for negligent homicide. Two of them pleaded guilty under the terms of a plea bargain. The third was later acquitted.