Wrong Route for Nutrients
Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.
An elderly man receiving feedings through a percutaneous enterostomy tube was prescribed intravenous total parenteral nutrition (TPN). A licensed practical nurse (LPN) mistakenly connected the TPN to the patient's enterostomy tube. His daughter (a retired nurse) asked her about it, and the RN on duty confirmed the error. The LPN disconnected the mistakenly placed (and now contaminated) line, but then prepared to attach it to the intravenous catheter. Luckily, both the patient's daughter and the RN were present and stopped her.
Free full text
Pape T. AHRQ WebM&M [serial online]. Febuary 2006.
Double Dosing, by the Rules
Cohen H. AHRQ WebM&M [serial online]. February/March 2009.
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
Reporting near-miss events in nursing homes.
Wagner LM, Capezuti E, Ouslander JG. Nurs Outlook. 2006;54:85-93.
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