GENT-L-KARE

Description of Event or Problem

OB (OBSTETRICS) PATIENT DEVELOPED ILEUS POST C-SECTION AND REQUIRED AN ENEMA. THE INSTRUCTIONS HAD BECOME SEPARATED FROM THE KIT AND THE RELATIVELY NEW NURSE, DID NOT REALIZE THAT THE END OF THE TUBING WAS A BLUE COLORED CAP. RATHER, SHE BELIEVED THIS WAS SOMETHING TO MEASURE THE AMOUNT THAT SHOULD BE INSERTED. THE CAP BECAME LODGED IN THE PATIENT'S RECTUM AND COULD NOT BE REMOVED MANUALLY. GI WAS CONSULTED AND REMOVED THE CAP VIA FLEXIBLE SIGMOIDOSCOPY. THE PATIENT COMPLAINED OF PAIN PRIOR TO REMOVAL, BUT HAD NO SIGNIFICANT SEQUALAE. RECOMMENDATION: DISTINGUISH THE CAP BY COLOR, TEXT DIRECTLY ON IT, OR OTHER MEANS, AS A WAY TO HIGHLIGHT THAT THIS IS AN ITEM TO BE REMOVED.