ISO analysis of a med error

  1. Please move this if it's in the wrong place.
    I did a search but didn't find what I was looking for. There was a case in CO with a NICU baby receiving the wrong dose of PenG (I think) which resulted in one of the first cases of nurses being prosecuted criminally. Nursing ____ (year) magazine did an amazing, in depth analysis of the med error. Does anyone remember either the year of the article or know where I can find it?
  2. Visit climberrn profile page

    About climberrn

    Joined: Jan '05; Posts: 78; Likes: 5


  3. by   Crocuta
    I believe the event you are looking for was reported in the May 1998 issue of Nursing and involved a newborn being injected with 10x the I.M. dose of PenG via I.V. Nursing's archive only has full text back to 2002, but I think this is the article from another source:

    There also appears to be a followup article in the June 1998 issue:

    Hope this helps. What a sad and tragic mistake.
  4. by   climberrn
    That's exactly what I was looking for. Thank you! The analysis was amazing...there were just so many places it went wrong.