ABSTRACT
An October 1996 fatal incident in Denver illuminates the critical intersection of patient safety and reliable EI&K transfer. In this case, three nurses were indicted for criminally negligent homicide and faced possible jail terms for their role in the death of a newborn who received IV penicillin G benzathine (Smetzer and Cohen 1998). A retrospective review uncovered 50 points of failure in the medication use system, including failures of information, evidence and knowledge transfer (Smetzer and Cohen 1998). An intervention at any one of these points of failure would have prevented the infant’s death (Committee on Identifying and Preventing Medication Errors et al. 2007). Points of failure included: faulty information interpreted from an outdated drug reference book, misreading of the dose by a pharmacist, incorrect route of administration, miscommunication with the child’s mother, and lack of institutional knowledge regarding treating of the condition. These failures were all sharp end challenges for this clinical team that placed the infant at risk.
