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Hospital regroups after patient accidentally given liquid cleanser

Date Posted: 2007-11-13

A bedside mix up at Okinawa Prefecture’s Southern Medical Center nearly caused a disaster, but a vigilant nurse realized the fluid being given to a patient was a cleanser, and not the water she thought it was.
The hospital is working with Yonabaru Town Police to determine how the liquid cleanser got into water bottles, and into a patient’s room. Authorities say the cleanser is used by the contract cleaning company in the hospital, but a cleaning company spokesman is denying his employees put the cleanser in the patient room. “No, no!” he said. “Nobody brought it into patient rooms.”
Medical Center officials say nurses infuse water to patients through drip infusion tubes, using water kept in bottles. That happened in this case, but the alert nurse thought “My God, it smells like cleanser” and immediately called a doctor. The patient had been given the cleanser twice, instead of water, but the doctor says the cleanser had been heavily diluted with water and caused no danger to the patient.
Southern Medical Center and Children’s Center is located in Naha City near the Expressway. Medical Center staff have held emergency training meetings to double check bottles in patient rooms, and to make sure all bottles are labeled. The cleaning company has been told to change the type bottles used for cleansers, and to keep them in storerooms. The hospital has apologized to the patient’s family.

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