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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.
 
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Resource Type:  Journal Article > Commentary

Setting of Care:  Residential Facilities

Target Audience:  Health Care Providers > Nurses

   Health Care Executives and Administrators

Clinical Area:  Allied Health Services > Nutrition/Dietetics

   Medicine > Internal Medicine > Geriatrics

   Nursing

Safety Target:  Medication Safety > Medication Errors/Preventable Adverse Drug Events > Administration Errors

Error Types:  Active Errors

   Latent Errors

   Near Miss

Approach to Improving Safety:  Communication Improvement > Communication between Providers

   Communication Improvement > Provider-Patient Communication

   Human Factors Engineering > Forcing Functions

   Human Factors Engineering > Medical Device Design

   Logistical Approaches > Nurse Staffing Ratios

   Culture of Safety

   Education and Training
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