Dosing error due to use of adult concentration of gentamicin injection rather than the pediatric concentration

A composite case is presented of a neonate who received an overdose of gentamicin injection due to confirmation bias. The adult dosage form (40 mg/L) was sent to the neonatal intensive care unit rather than the pediatric form (10 mg/L). The baby received the volume that would have provided a 2.5 mg/kg dose of the 10 mg/L dosage form were used, resulting in gentamicin first dose concentrations four-fold higher than expected. The nurse, familiar with the usual dosage form, noted that the vial contained gentamicin, but failed to notice the different strength because adult doses are not usually sent to the unit. The right drug was confirmed, but not the difference in dose. Blaming individuals for these errors does not prevent the problem from occurring again. It is important to consider the system-related factors that lead to such errors and institute safeguards that can aid in prevention of the error.