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A 78-year-old stroke victim who couldn't swallow had a gastrostomy tube inserted for liquid feedings. She also had an indwelling urinary catheter.
To control diarrhea caused by the tube feedings, her doctor ordered a kaolin-pectin mixture (Kaopectate). During shift change, a nurse was puzzled by the milky white fluid in the patient's urinary collection bag.
Here's what happened. Earlier in the day, a medication nurse had turned off the feeding pump and disconnected what she thought was the gastrostomy tube. She instilled the Kaopectate, then reconnected the catheter to restart the feeding. What she'd actually done was put the Kaopectate into the patient's urinary catheter, not the gastrostomy tube. The medication went directly into the patient's bladder.
The nurse who discovered the mistake called the patient's doctor, who ordered a bladder irrigation and antibiotics. The patient's urinary catheter and collection bag were replaced.
Occasionally we hear about nurses who inadvertently administer medications or liquid feedings in the wrong catheter, tube, or body cavity. These errors may cause serious injuries-even death. So play it safe: Always trace a length of tubing from its distal to its proximal end. Better yet, label all tubing so that it's virtually impossible to get two lengths of tubing mixed up. And make sure unnecessary tubes are discontinued as early as possible.