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ISMP Medication Safety Alert


Patients are increasingly getting much of their care at home. Yet if a patient is to be cared for appropriately at home, families and caregivers need clear and adequate instructions from health care professionals to be sure that such care is safe and effective. The following story shows why.

A three-year-old cancer patient who couldn't eat was discharged from the hospital with a feeding (nasogastric) tube in place from her nose to her stomach. Her mother was taught to unclog the feeding tube by drawing ginger ale into a syringe and injecting it through the tube.

When the child was later readmitted for routine chemotherapy, she developed an infection and had to receive antibiotics intravenously (IV) through a tube inserted into the child's veins - a peripherally inserted central catheter (PICC). The antibiotic IV had to continue at home, even after the child was discharged, and follow-up was arranged with the hospital's home care department.

However, soon after the child went home, her antibiotic IV (PICC) clogged. The patient's mother mistakenly assumed that the ginger ale method of unclogging the nasogastric tube would also work for unclogging the antibiotic IV line. Luckily, the home care nurse arrived just in time to prevent the terrible tragedy that certainly would have resulted had the mother injected ginger ale into the child's veins.

No patient should be sent home on IV therapy unless the patient and home caregivers have gotten clear and complete instructions from a health care professional about what to do if complications, including clogged lines, arise. Patients and their caregivers can be an important safety factor in their own medication use by insisting on clear and complete names of medications, dosages, explanations of what the medication is intended to do, and full instructions about what to do if complications or emergencies arise. Keep and share with your health care provider a complete and up-to-date list of the medications you are taking. And, always repeat related instructions to the health care provider to make sure you've understood correctly.

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