[Phosphate containing enemas: one undervalued risky practice? The management of an adverse event]

The phosphate-containing enemas are widely used, both to manage constipation and as a preparation for endoscopic procedures and surgery in adults and children. Many studies report that the use of these laxatives can be dangerous.

To identify possible prevention strategies starting from a severe adverse reaction due to repeated administrations of phosphate enemas.

A working group was started, the literature was reviewed and recommendations for an appropriate use of enemas were discussed and implemented, to improve patients' safety.

Phosphate-containing enemas were replaced with 125 ml water enemas; recommendations were spread to strongly limit the use of phosphate containing enemas and the use of laxative in the first and second semester of 2012, were confronted showing a change in habits and a reduction in the use of phosphate containing enemas.

The implementation of several strategies, originated from an adverse event, succeeded in modifying the use of laxatives and phosphate-containing enemas.