This was posted buy thedoctor on a bb forum i post on.
quote:
Baby given overdose of testosterone
30 June 2005
By NIKKI MACDONALD
A baby given 10 times the prescribed dose of testosterone began to grow pubic hair and was left vulnerable to a painful side effect.
The nurse who accidentally gave the overdose, which left the baby irritable, angry and often inconsolable, breached the code of patient rights, the Health and Disability Commissioner has found.
The infant, identified as Baby A, had a rare congenital condition that resulted in a very small penis. To avoid later teasing, the baby was prescribed a course of three 25-milligram injections of testosterone enanthate one month apart, to enlarge its penis to normal size.
A nurse gave the first injection without any problem, but when Baby A's mother returned for the second dose, a different nurse - unfamiliar with the drug - failed to check the original prescription and injected 10 times the prescribed amount by mistake. On re-reading the pharmacy instructions, the nurse - known as Ms B - realised to her horror that she had overdosed the baby.
"I phoned (Baby A's mother) several days later to sincerely apologise for the mistake I made," Ms B told the commissioner. "Being a mother myself, I could only imagine what she was feeling, but I was and am so deeply sorry for my actions."
Baby A's paediatrician warned possible side effects of the overdose included painful erection, which could be difficult to manage and need ice packs. However, he did not believe the overdose would cause great harm and advised Baby A's doctor not to try to remove any of the injected drug.
After the injection, Baby A was irritable, quite angry and often inconsolable, the paediatrician said. Though expected, the side effects may have been exacerbated by the large dose. The baby did not suffer any painful erections.
AdvertisementAdvertisementThe commissioner's nursing expert, Rosemary Minto, found Ms B should not have given the injection, as she had no paediatric experience and it was outside her scope of practice. She should have sought advice from the baby's doctor.
Commissioner Ron Paterson found Ms B had breached the code of patients' rights but decided not to take the matter further, as she had apologised, undertaken further training and written vaccination guidelines for other nurses.
http://www.stuff.co.nz/stuff/0,2106,3329828a11,00.html