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A home health nurse was assigned to care for an elderly man who had a urinary tract disorder. He had just received an indwelling catheter, which needed twice-daily irrigations.
The man's wife volunteered to learn the irrigation procedure. The nurse showed her how to do it, using her own equipment and solution. Then she called a local pharmacy and asked them to deliver irrigating equipment and solution to the home.
The pharmacy delivered the equipment and solution, with several other containers of oral medications for the patient. The patient's wife carefully read the instructions on each container and followed them to the letter. One bottle was labeled: Acetic acid solution. Use 1/2 cup twice daily. So she measured exactly 1/2 cup into a glass and gave it to the patient to drink.
The patient immediately spit out the solution and refused to take another sip. His wife reported this to the home health nurse, who realized what had happened and explained that this was the irrigating solution. She assured the patient and his wife that he'd be all right because he hadn't actually drunk any solution.
An important lesson can be learned from this incident. Patients or family members should be given specific instructions for administering medications and performing procedures. This won't take any extra time, but it may prevent a serious error.