Madison Wills worked night shift on a neonatal intensive care unit (NICU) at a major medical center. She assumed the care of a very sick premature infant who weighed 1 kg (a little over 2 lb). Sylvia Smithson had been the infant’s nurse during the day shift. Sylvia had started the infant’s intravenous (IV) antibiotic infusion at 6:30 p.m., just before shift change. She reported that the infant’s IV line in his arm was flowing without difficulty and the IV site had no redness or swelling.
When Madison assessed the infant at 7:45 after the end-of-shift report, she noted that the baby’s arm was swollen and that the IV had infiltrated (was no longer in the vein). When she stopped the medication, she also noted that the dose on the antibiotics was incorrect and was much too large for a very small infant.
Question: What could have been done to prevent the errors?
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