Ask Dr Nerenberg | Health and Fitness

Hospital case study – Finding it hard please help. Thank you in advanced?

A woman with a medical history of epilepsy was hospitalised and commenced on IV fluids for gastrointestinal complications. A jejunostomy was performed to facilitate feeding and administration of oral medications including oral liquid phenytoin. Complications developed and the patient was commenced on total parenteral nutrition. Her orders were changed to IV orders. About two weeks later a nurse who had previously administered oral medications to the patient prepared two IV medications and had these checked.
The nurse then obtained the oral phenytoin liquid, measured 5mL into a cup and then drew it into a syringe. She administered the medications to the patient including the oral phenytoin liquid via central venous catheter (CVC). The patient complained of pain at the injection site and commenced dry retching before losing consciousness. Staff commenced resuscitation but the woman could not be revived.

As the previous poster indicated, an oral medication was injected into the blood stream. Oral medications are meant to be absorbed into the blood via the gastrointestinal tract. So the nurse must have thought she/he was injecting into the j-tube.Contributing factors to the error are (1) human error, perhaps also a lack of knowledge to differentiate between a medication intended for a j-tube vs. CVC, (2) and failure to verify the route/dose that was ordered. Errors like this can be hopefully prevented by closer attention to detail when administering medications.

General Overview of the TPN Sierra One AKA Project Salvo

Total Parenteral Nutrition: Webster’s Timeline History, 1970 – 2007 $28.95 Webster’s bibliographic and event-based timelines are comprehensive in scope, covering virtually all topics, geographic locations and people. They do so from a linguistic point of view, and in the case of this book, the focus is on “Total Parenteral Nutrition,” including when used in literature (e.g. all authors that might have Total Parenteral Nutrition in their name). As such, this book represen…