The PSNet Collection: All Content
Search All Content
An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system.
ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.
Banks MA. Specialty Pharmacy Continuum. September 15, 2023.
ISMP Medication Safety Alert! Acute care edition. June 1, 2023; 28(11):1-6.
Horsham, PA; Institute for Safe Medication Practices: April 2023.
Pharmacy Practice News Special Edition. December 13, 2022: 43-54.