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An inexperienced graduate nurse was asked to administer medications one evening. Although nervous, she completed the task without problems. When she arrived at work the next day, though, she was asked to fill out two incident reports for failing to administer certain medications to two patients.
What had happened? During her shift, the nurse had noted two new orders for gallbladder series the next morning. But she didn't know these orders initiated a well-established protocol that included administering Bilopaque capsules, which contain a contrast medium used in cholecystography. The nurse had no idea she was to administer these capsules the night before the test.
Because the capsules hadn't been administered, the patients' tests had to be postponed. The patients experienced added anxiety as well as a longer and more costly hospital stay.
Protocols often include administration of laxatives, sedatives, and .contrast media. But unless the complete protocol appears somewhere in the patient's chart, parts of it may be missed, especially when a nurse is unfamiliar with practices on the unit. To ensure that this doesn't happen, preprinted orders should be placed in the chart.
To avoid making a similar error, be sure to look for the protocol whenever you see an order for a diagnostic procedure. If the protocol isn't there, check with the doctor or a nurse who's familiar with the unit's procedures.