Problem
A 56-year-old female with hyperkalaemia was in a medical intensive care unit and was ordered to receive sodium polystyrene sulfonate (Kayexalate®) via rectal administration. The nurse caring for this patient inadvertently administered the medication through the urinary (Foley) catheter instead of the rectal tube. The patient developed cystitis because of the error, which required a consult by urology to determine treatment options.
Australian Commission on Safety and Quality in Health Care has launched the Safety and Quality Improvement Guide Standard 4: Medication Safety and developed the Medication Management Pathway to manage the safe and effective use of medicines for patients at each episode of care. Referring to this Pathway, identified in which phase of medication management pathway that this error occurred.