Key Element

Latent Failures

Active Failures

Drug Information

  • Insufficient information on volume of medication that can be safely administered IM to neonates (maximum of 0.5 ml per injection).

  • Insufficient drug information regarding significant serious effects of IM injection of the drug in neonates.

  • Dispensed medication with directions to administer 2.5 ml of drug IM to neonate, requiring five IM injections.

4. Drug Administration Phase

Drug Information

  • Insufficient drug information about various forms of penicillin G (never used penicillin G benzathine in practice, nonformulary drug).

  • Inadequate drug references: penicillin G benzathine is frequently referred to in texts with the ambiguous synonyms “crystalline penicillin” and “aqueous suspension.”

  • Inadequate drug reference: Neofax’95 does not mention penicillin G benzathine in monograph, but notes aqueous crystalline penicillin G IV push is used to treat congenital syphilis; no specific warnings that penicillin G benzathine (or procaine) can be administered IM only.

  • Inadequate drug reference: NICU Medication Administration does not mention penicillin G benzathine in monograph on penicillin G.

  • Inadequate resource text: 1994 Red Book does not

  • Misunderstood benzathine to be brand name for aqueous penicillin G.

  • Incorrectly thought that aqueous crystalline penicillin G and penicillin G benzathine were the same drug; consequently, problem with IV administration went unrecognized.

  • Made decision to administer the drug IV to avoid pain from multiple IM injections.

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement