Description of Event or Problem · 1
A BOLUS TUBE FEEDING WAS ADMINISTERED IN A TENCKHOFF CATHETER IN ERROR. THE RN THOUGHT THE PORT WAS A PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE. THE PT HAS TENKOFF, QUINTON AND PEG TUBES. APPROXIMATELY 300 CC OF NOVOSURE RENAL AND MORNING MEDICATIONS WERE ADMINISTERED. MEDICATIONS INCLUDED COLACE, KEPPRA, PRINOVIL, LOPRESSOR, PAXIL AND SENNA. THE NURSE HAD GONE INTO THE PT'S ROOM TO PERFORM A PHYSICAL ASSESSMENT OF THE PT. AT THAT TIME, SHE NOTED THE PT HAD A QUINTON CATHETER. SHE CAME BACK LATER THAT MORNING TO ADMINISTER MORNING MEDICATIONS AND NOTED THAT WHAT SHE THOUGHT WAS THE PEG TUBE LOOKED DIFFERENT. THE PT WAS WEARING AN ABDOMINAL BINDER OVER THE INSERTION SITE TO PREVENT HIS PULLING AT THE LINES. THE RN DID NOT REMOVE THE BINDER TO VISUALIZE THE LINES. SHE CHOSE THE LINE SHE THOUGHT WAS THE CORRECT ONE AND PREPARED TO ADMINISTER THE MEDS AND A BOLUS TUBE FEEDING. SHE ASPIRATED ABOUT 1 - 2 CC OF CONTENTS AND PROCEEDED TO ADMINISTER THE MEDICATIONS AND FEEDING. AFTER THE ADMINISTRATION, SHE SAT THE PT UP FOR BATHING AND REPOSITIONING. AT THIS TIME, THE ABDOMINAL BINDER WAS REMOVED AND SHE NOTICED THE PEG TUBE WAS ACTUALLY ABOVE THE TUBE SHE USED FOR THE MEDICATION/FEEDING ADMINISTRATION. THE PHYSICIAN WAS IMMEDIATELY NOTIFIED AND SHE WAS INSTRUCTED TO ASPIRATE, WHICH RESULTED IN A RETURN OF 200CC. HOURLY CAPD EXCHANGES WERE ORDERED UNTIL THE ASPIRATE WAS CLEAR AND THEN THE CAPD ORDER WAS CHANGED TO EVERY TWO HOURS. AS OF FOUR WEEKS LATER, THE PT HAS RETURNED TO HIS BASELINE STATUS (PRIOR TO EVENT) WITH STABLE VITAL SIGNS AND IS STILL HOSPITALIZED. THIS INCIDENT WAS DUE TO A MISCONNECTION.