Patient Care At Risk: Preventing Medication Errors

This medication error case study discusses a tragic claim involving a newborn infant. We hope the case highlights medication safety processes with an emphasis on reducing human error.

Hands Holding Syringe

Preventing medication errors is a top priority of all healthcare organizations due to the terrible consequences they can have on patient safety.

This medication error case study discusses a tragic claim involving an overall healthy newborn delivered in a hospital setting. We hope that by discussing the case, healthcare facilities consider their medication safety processes and procedures, and how they might combat human error within their organizations.

The Patients

A mother arrived at the hospital in spontaneous labor and delivered vaginally. The baby and mother were then moved to a mother-baby floor for continued monitoring.

Post-birth testing revealed that the infant’s RPR testing was reactive at 1:2 and the pediatrician ordered IV penicillin protocol. The mother was given orders by her physician for the injectable medication, bicillin.

The Case

Two days after delivery, the baby was due for its next dose of IV penicillin. Medication was placed in the infusion pump. Fifteen minutes later, the baby was returned to the mother’s room.

An hour later, it was noted that the baby was difficult to rouse, the right-hand IV was no longer flushing, and the infusion was incomplete. As a result, the baby was taken to the nursery. Eventually, a new IV was started on the right foot, and the IV infusion was continued.

Approximately three hours after the infant’s infusion was completed, it was time for the mother’s next dose of bicillin to be administered. When the nursing staff went to the medication storage cooler, it was discovered that the mother’s medication was missing, and the infant’s penicillin dose remained in the cooler. It became apparent that the mother’s bicillin was inadvertently given to the infant via the infusion pump.

Within an hour of the discovery, the infant was transported out for a higher level of care. Unfortunately, the bicillin caused significant damage to the infant’s tissues, resulting in a colostomy, lower limb amputations, and skin debridement.

The case was reported immediately following the adverse drug event. It was settled quickly on behalf of the facility.

Reducing Medication Errors

We can only speculate why the nurse delivered the wrong medication to this infant. In this case, human factors contributed greatly to the poor outcome, as the only thing preventing this error from being made was the human in charge of administering the medication.

As human beings, only one thing is certain — we all make mistakes. Unfortunately, this mistake resulted in lifelong harm to an infant.

In James Reason’s famous Swiss Cheese model, he illustrates how the holes in Swiss cheese represent weaknesses in processes. When the holes all line up just right, the result is an opportunity for error to make it through to a patient — and cause patient harm. The goal is to incorporate layers of hard stops along the way using standardized processes and technology to help healthcare workers recognize and resolve the error before it reaches the patient at all.

Dr. Scott Shappell and Dr. Doug Wiegmann developed the Human Factors Analysis and Classification System (HFACS) that describes four categories of latent and active human factor failures that occur and lead to an adverse event. These categories should be incorporated into event investigations to assist in root-cause analysis identification of potential human factors that may need to be controlled to prevent errors in the future.

Consider these tips while reviewing medication storage and administration processes and policies in your facility:

  • Store adult and pediatric medications separately. The mother and infant are two separate patients, so their medications should not be stored together.
  • Consider color-coding medication labels specific to pediatric medications.
  • Use a process of pulling medications for delivery from an automated, patient-profile-driven system. Medications ordered for a specific patient will only be available for access.
  • Use a bar-coding and scanning process at the bedside before administration of the medication. Educate and monitor staff for compliance during the use of these scanning systems.
  • Standardize the process of patient identification using the name and date of birth in comparison to the identification band and the medication administration record.
  • Print and attach warning labels to medication that indicate that they are for injection only or IV infusion only.
  • Reduce distractions while preparing medications for administration by using a medication room with a closed door.
  • Implement quiet zones for medication preparation areas where the nurse is not interrupted while preparing medications. Encourage reduced noise levels to limit distractions.
  • Enforce the Five Rights of Medication Administration that create a framework for medication safety and administration — right medication, right dose, right time, right patient, and right route.

Medication Safety Tools and Resources

There’s no doubt that this case was tragic and possibly preventable. It also illustrates the need for healthcare facilities to consistently review medication safety processes and procedures — especially regarding how to reduce the possibility of human error in medication preparation, delivery, and administration to patients.

LHA Trust Funds has gathered a robust collection of medication safety tools and resources from the American Academy of Pediatrics, the American Society of Health-System Pharmacists, the Institute for Safe Medication Practices, and more. Visit our Medication Safety Toolkit to access these resources to promote and reinforce safe medication practices within your organization.

About the Authors


Jamie Lamb
Director of Claims Operations, LHA Trust Funds

Jamie Lamb began her career in claims in 1997. Her experience includes handling multi-line claims in the areas of general liability, medical malpractice, automobile liability, commercial and personal property, excess and umbrella policies, and professional liability. Her experience comes as a former Manager and Litigation Specialist for the American National family of companies. She has been highly involved in the education and training of both internal and external customers her entire career. Ms. Lamb attended both Evangel University in Springfield, Missouri, and Loyola University in New Orleans.

Stacie Jenkins 150

Stacie Jenkins, RN, MSN, CPSO
Vice President of Patient Safety and Risk, LHA Trust Funds

Stacie Jenkins is a registered nurse with a master’s degree in nursing informatics. She has more than 20 years of experience in healthcare, working in patient care and quality/performance improvement positions. As the Vice President of Patient Safety & Risk at LHA Trust Funds, she works closely with hospital administrators, risk managers, and nursing staff to improve patient safety and establish best practices. She conducts on-site assessments and gives presentations designed to help clients address their patient safety risk management challenges.

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