While preparing for drug administration, neither of the nurses noticed the 10-fold overdose or the manufacturer’s label on the syringe “IM use only.” They had no idea that IV administration would be lethal because the drug is insoluble and obstructs blood flow in the lungs required for the transfer of oxygen from the baby’s airways. The manufacturer’s warning is very difficult to see because it is not prominently placed; it can be viewed only if the syringe is rotated 180 degrees away from the drug name. The nurses began to administer the first syringe of Permapen slow IV push. After about 1.8 ml had been administered, the infant became unresponsive, and resuscitation efforts were unsuccessful. Later, upon autopsy, it was confirmed that the baby had not had congenital syphilis, and therefore never needed treatment.

The three nurses involved in this medication error were later indicted by a grand jury for negligent homicide. Two of the nurses agreed to legal sanctions before the trial, but a third pled not guilty, and a trial ensued. Expert testimony presented during the trial served as convincing evidence that, while the nurse and her colleagues had played a part in the tragedy, more than 50 latent1 and active failures had occurred throughout the medication-use process (see Table I-1), most of which, such as the poor syringe labeling, the pharmacist’s mistake, and the confusing drug information, had not been under the control of the nurses. It was these failures that had set the stage for the nurses’ tragic mistakes. The experts advised against the tendency to focus on the errors of the providers. Had even one of these failures not occurred, either the accident would not have happened, or the error would have been detected and corrected before reaching the infant. Since most of what people do is governed by the system within which they act, the causes of errors belong to the system and often lie outside the control of individuals, despite their best efforts. This case illustrates that medication errors are almost never the fault of a single practitioner or caused by the failure of a single element. The analysis presented during the trial had a powerful influence on the jury, which acquitted the nurse in the one case that was tried. The lesson learned from this case study is that we must look beyond blaming individuals and focus on the multiple underlying system failures that shape individual behavior and create the conditions under which medication errors occur.


Weaknesses in the structure of an organization, such as faulty information management, ineffective personnel training, or faulty drug labeling. By themselves, latent failures are often subtle and may cause no problems. Their consequences are hidden, becoming apparent only when they occur in proper sequence and combine with active failures of individuals to penetrate or bypass the system’s safety nets (Reason, 1990). Providing an optimal level of medication safety requires that we recognize and correct the latent failures in the system.

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