Medication Mix-Up Leads to Patient Death. Luciano Sanchez, PharmD and Patrick Romano, MD, MPH | November 30, 2023

https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death In this WebM&M Case, an 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system. After the patient had difficulty drinking the solution, the nurse gave the rest of the liquid through a feeding tube bag. The medication mix-up was identified around midnight and the patient died about 7 hours later.