Pediatric Errors and Disclosure

Read the following case study regarding look-alike and sound-alike medication errors.

A newborn incorrectly received methylergonovine maleate, a synthetic ergonovine analogue indicated for the management of postpartum atony. What was actually ordered was the hepatitis B vaccine, Engerix-B.

While these two medications do not sound alike, they are similar looking and were stored in the same cabinet in the perinatal area. The infant sustained diminished urinary output for a twelve-hour period and required an additional day of hospitalization for monitoring.

In your initial post, pose a potential organizational reporting strategy that you think would be appropriate in this situation. What information should be disclosed in this case to the responsible adult family member? How does the patient being a minor impact this process?

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