Stage of error | Description of case |
---|---|
Administration | A child admitted with newly diagnosed type I DM without DKA developed moderate DKA while in the hospital due to omissions of insulin dose |
For a newborn, a nurse secured IV line and inadvertent intra-arterial administration of Ampicillin and Gentamicin lead to extravasation induced necrosis | |
A child with pharyngitis who was taking IV cloxacillin developed infiltration at the injection site | |
Prescribing | An 8Â year old severely malnourished child with the diagnosis of CHF secondary to chronic valvular heart disease was receiving Lasix 20Â mg PO BID, and digoxin 0.125Â mg P.O per day, who latter developed irritability |
Over sedation due to an overdose of tramadol in a child with moderate pain | |
A child developed maculopapular rash with urticaria to cloxacillin with previous history of penicillin allergy | |
Monitoring | A 6Â month infant with severe pneumonia was put on crystalline penicillin but failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy cause the death of a patient |