Baby Edward, a preterm infant with respiratory
distress requiring ventilation, was prescribed
intravenous gentamicin for a serious infection.
The intensive-care nurse and pediatrician were
extremely busy due to the admission of very
pre-term twins. The drug was administered
90 minutes later than prescribed.
Discussion
– Identify all the possible factors that may have
been present at the time of this incident.
– Should this incident be reported?
– Discuss the different methods for reporting
incidents.
