Problem:
An infant was born to a mother with a prior history of syphilis; decision was made to treat the infant from congenital syphilis. Order was written for one dose of "Benzathine Pen (penicillin G150, 000U IM".
Physicians, nurses, and pharmacist unfamiliar with the treatment, Pharmacist misread the dose in both sources as 500,000 units/kg, a typical adult dose, instead of 50,000 units/kg, due to lack of a pharmacy procedure, error was not detected, nurse unfamiliar with the various form of penicillin G. After about 1.8 ml was administrated, the infant become unresponsive
1) A risk manager's role in addressing the events described in the case study The Joint Commission requirements for reporting sentinel events for a hospital
2) Steps a risk manager must take to address these events