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Search results for "Cognitive Errors ("Mistakes")"
Cases & Commentaries
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Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RN; June 2015
A hospitalized older man with a complicated medical history had not voided in several hours. The patient voided just prior to catheter insertion, which produced no urine, and the nurse assumed that meant the patient's bladder was empty. Two hours later the patient complained of discomfort and a blood clot was found in his tubing. Continuous bladder irrigation was ordered, but the pain became worse. Urgent consultation by urology revealed that the urinary catheter was not in the bladder.