A young child's parent has a history of contracting syphilis so it was decided to give the child treatment from congenital syphilis. Namely, a prescription of one (1) dose of Benzathine Penicillin G150, 000U IM.
Unfortunately, the attending pharmacist misread the dose as 500,000 units/kg - the dosage typically used to treat adult patients - instead of the significantly reduced does of 50,000 units/kg that had been prescribed for the child. Thanks to lack of sufficient checks in the pharmacy procedure, this mistake went undetected. The nurse attending the child in question was unfamiliar with penicillin G and so also failed to see the error.
After about 1.8 ml was administrated, the child became unresponsive.
Please outline the following in accordance with the scenario given above:
- Processes and techniques that a risk manager would take to investigate, prevent, and control these types of events now and in the future
- Internal and external individuals and entities that might be involved in this situation, why, and in what capacity.