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ISSN 2007-932X (Electronic)
Órgano Oficial de Difusión de la Comisión Nacional de Arbitraje Médico

2020, Number 4

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Rev CONAMED 2020; 25 (4)

Administration of a sodium hypochlorite enema: a patient safety incident in nursing practice

Molina-Jiménez ME, Ensaldo-Carrasco E, Pineda-Olvera J, Meneses-González F, Lezana-Fernández MÁ

Language: English
References: 14
Page: 188-192
PDF size: 85.36 Kb.


ABSTRACT

Adverse events related to flaws in administering enemas are usually related to dosage errors which may cause unintended harm to the patient, and studies documenting incidents and contributing factors are scare. Therefore, the objective of this study was to analyze a complaint-case, registered at the National Commission of Medical Arbitration, due to the erroneous administration of a sodium hypochlorite enema. We describe the clinical case of a 32-year-old female was scheduled for laparoscopic surgery in a private hospital. Before this procedure, the treating physician indicated the administration of a soap-based evacuating enema. The enema was administered by a nurse, who mistakenly administered an enema containing sodium hypochlorite which caused periproctitis and toxic colitis. Training, follow-up, and prevention in the application of routine procedures in clinical areas by nursing staff are key to avoiding adverse events.


REFERENCES

  1. Núñez SM, Leighton SS, Díaz RF. Severe tetany due to phosphate enemas use, case report. Rev Chil Pediatr. 2017; 88 (3): 383-387.

  2. Throckmorton T, Etchegaray J. Factors affecting incident reporting by registered nurses: the relationship of perceptions of the environment for reporting errors, knowledge of the nursing practice act, and demographics on intent to report errors. J Perianesthesia Nurs. 2007; 22 (6): 400-412.

  3. FDA Drug Safety Communication: FDA warns of possible harm from exceeding recommended dose of over-the-counter sodium phosphate products to treat constipation | FDA [Internet]. [cited 2020 Feb 28]. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-warns-possible-harm-exceeding-recommended-dose-over-counter-sodium.

  4. Poth EJ, Jacobsen LW, Dunlap W. Control of tumor transplantation after primary anastomosis of the colon. Surgery [Internet]. June 1, 1961 [cited August 28, 2020]; 49 (6): 723-726. Available in: http://www.surgjournal.com/article/0039606061901477/fulltext.

  5. Scammell BE, Phillips RP, Brown R, Burdon DW, Keighley MRB. Influence of rectal washout on bacterial counts in the rectal stump. Br J Surg [Internet]. on Jul 1, 1985 [cited on Aug 28, 2020];72(7):548–50. Available in: http://doi.wiley.com/10.1002/bjs.1800720717.

  6. Valverde A, Msika S, Kianmanesh R, Hay JM, Couchard AC, Flamant Y et al. Povidone-iodine vs sodium hypochlorite enema for mechanical preparation before elective open colonic or rectal resection with primary anastomosis: A multicenter randomized controlled trial. Arch Surg [Internet]. on Dec 1, 2006 [cited on Aug 28, 2020]; 141 (12): 1168-1174. Available in: https://jamanetwork.com/journals/jamasurgery/fullarticle/399425.

  7. Mattox EA. Strategies for improving patient safety: linking task type to error type. Crit Care Nurse. 2012; 32 (1): 52-78.

  8. Dougherty, Lisa & Lister S. Clinical Nursing Procedures. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 2004, pp. 316-317.

  9. Luengo-Martínez C, Paravic-Klijn T, Burgos-Moreno M. Professionalism in nursing: a review of the literature. Nursing Univ [Internet]. 2017; 14 (2): 131-142. Available at: http://dx.doi.org/10.1016/j.reu.2017.02.001.

  10. Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. Int J Nurs Pract [Internet]. 2010 Apr 1 [cited 2020 Jun 21]; 16 (2): 112–24. Available at: http://doi.wiley.com/10.1111/j.1440-172X.2009.01815.x.

  11. Nursing notes: a look at its quality [Internet]. [Cited August 10, 2020]. Available at: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120-55522016000200015.

  12. Taylor H. An exploration of factors affecting nurse recordkeeping. [Internet]. Vol. 12, British Journal of Nursing (Mark Allen Publishing). MA Healthcare London; 2003 [Cited 2020 Sep 15]. Available at: https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2003.12.12.11338.

  13. Luengo-Martínez C, Paravic-Klijn T, Burgos-Moreno M. Professionalism in nursing: a review of the literature. Nursing Univ [Internet]. 2017; 14 (2): 131-142. Available at: http://dx.doi.org/10.1016/j.reu.2017.02.001.

  14. International Patient Safety Goals|Joint Commission International [Internet]. [Cited 2020 June 19]. Available at: https://www.jointcommissioninternational.org/standards/international-patient-safety-goals/.




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