Physicians, nurses, and pharmacist unfamiliar with the
treatment, Pharmacist misread the dose in both sources as 500,000 units/kg, a
typical adult dose, instead of 50,000 units/kg, due to lack of a pharmacy
procedure, error was not detected, nurse unfamiliar with the various form of
penicillin G. After about 1.8 ml was administrated, the infant become
unresponsive

a. A risk manager’s role in addressing the events described
in the case study The Joint Commission requirements for reporting sentinel
events for a hospital

b.Steps a risk manager must take to address these events