Infant ‘gets mother’s medication’ at Ctg hospital, lands in NICU

Newborn in Chattogram Given Mother’s Anti-D Injection, Ends Up in NICU

Bdbusinessdaily.com – A medication mix-up at a private hospital in Chattogram left a newborn in the neonatal intensive care unit after staff allegedly administered an injection meant for his mother directly into the infant. The episode, which unfolded on 5 September at the Center for Specialized Care and Research (CSCR), has drawn scrutiny over how bedside verification protocols function in postpartum wards and whether a single nurse’s lapse can be treated as the full explanation for what happened.

Why the Injection Mattered

The drug in question, Rhophylac 300 (Human anti-D [Rh] immunoglobulin), is a standard prophylactic given to mothers whose blood type is Rh-negative when they deliver a baby with an Rh-positive blood group. Without the shot, maternal antibodies can form and attack red blood cells in subsequent pregnancies, a condition known as Rh isoimmunisation. In this case, 34-year-old Shakila Yasmin was found to carry A-negative blood while her newborn carried A-positive blood, making the postpartum injection medically indicated for her alone. The family stated that Shakila’s husband, Mohammad Hasan, purchased the vial from outside the hospital and personally handed it to the nurse on duty, explicitly noting that it was prescribed for the mother.

What the Family Says Happened

According to the family’s account, nurse Shafia Akter received the vial and then injected the newborn rather than Shakila, even though the mother had specifically told the nurse the medicine was for her. Chowdhury Mohammad Rifat, a close relative of the baby who said he was present in the room, described the moment to reporters. Within minutes of the injection, the family reported, the infant’s body temperature dropped and the colour of the child’s skin began to shift — signs consistent with acute physiological stress in a newborn.

Paediatrician Dr Muhammad Javed Bin Amin Chowdhury advised moving the baby to the NICU, and the child was transferred there shortly afterward. A hospital doctor later acknowledged the episode as a “medical error,” the family said. Over the following hours the infant’s condition stabilised, and the baby was eventually moved from the intensive-care bed to a regular cabin.

Family Demands Broader Accountability

Hasan, the baby’s father, pushed back against what he sees as a narrow framing of responsibility. He argued that singling out the nurse obscures systemic failures in supervision and verification.

“Putting the blame only on the nurse will keep the real issue hidden. The investigation should also examine whether the doctors on duty and the hospital authorities had adequate oversight before the injection was administered,” he said.

He further demanded that the hospital assume responsibility should the child develop any physical complications down the line, noting that neonatal exposure to an adult-dosed immunoglobulin preparation carries risks that may not surface immediately.

Hospital Response: Suspension, Investigation, and External Review

Dr Mohammad Salahuddin, chief operating officer of CSCR, confirmed that the nurse involved had been suspended pending the outcome of an internal inquiry. He stressed that the hospital regarded the episode as wholly unacceptable.

“We have suspended the nurse concerned and are investigating the incident. Such an incident is in no way acceptable. Further action will be taken after receiving the investigation report,” he said.

Salahuddin added that the hospital intended to convene a medical board drawing on specialist physicians from Chattogram Medical College to evaluate the baby’s condition and chart any further treatment. At the time of his remarks, he reported the newborn was stable — feeding, crying, and passing stool — and that laboratory results were under review. The hospital pledged to follow the consultants’ recommendations for any additional tests or interventions.

Police Involvement and the Question of Formal Complaint

Mohammad Mozammel Haque, officer-in-charge of Panchlaish Model Police Station, told reporters that a police team had been dispatched to the hospital after the incident came to their attention. However, no written complaint had been lodged with the station as of his statement.

“If the baby gets better after 12 hours of observation, that is good. Otherwise, legal action will be taken if the affected party later approaches us with a complaint,” he said.

Haque also noted that police had not yet independently verified whether the infant had actually been admitted to the NICU or assessed the child’s present medical status. Officers were continuing to collect information from both the family and hospital staff.

Broader Context: Verification Gaps in Postpartum Care

The incident highlights a recurring vulnerability in hospital workflows: the moment a medication crosses from pharmacy or family hands into a nurse’s tray, the chain of verbal confirmations — patient identity, drug name, dose, route — becomes the sole safeguard. In a busy postpartum ward where a mother and her newborn share a bed, the visual proximity of two patients can blur the target of an injection if the administering nurse does not pause to re-verify. International patient-safety frameworks, including those promoted by the World Health Organization, emphasise a “five rights” check (right patient, right drug, right dose, right route, right time) precisely to prevent the kind of substitution error described here.

For families in Chattogram and across Bangladesh, the episode raises practical questions: How clearly must a parent state that a purchased medication is for the mother rather than the baby? Does a hospital’s duty of care extend to confirming, independently of the nurse’s word, that the intended recipient matches the prescription? And what oversight structures exist between the moment a vial enters the ward and the moment a needle enters a vein?

Until the internal investigation concludes and the external medical board reports, the baby’s family will continue to monitor for any delayed effects. The hospital has said it will provide whatever tests and treatment the consultants deem necessary. For now, the child remains under observation, and the question of institutional accountability awaits the findings of the inquiry.