قصور پزشکی به دنبال تجویز فنوباربیتال به جای فنازوپیریدین در بیمار مبتلا به عفونت ادراری
کد: G-1089
نویسندگان: Alireza Ghassemi Toussi © ℗
زمان بندی: زمان بندی نشده!
دانلود: دانلود پوستر
خلاصه مقاله:
خلاصه مقاله
Introduction: A young lady goes to the doctor because dysuria. The doctor prescribes phenazopyridine 100 mg 3 times a day. However, in the electronic prescription registration system, Phenobarbital 100 mg 3 times a day is prescribed by mistake. The pharmacy did not pay attention to the diagnosis of the disease and other drugs and gave the patient 100 mg phenobarbital tablets 3 times a day. Method and Material: Patient feels drowsy after taking phenobarbital, but she doesn't pay attention and thinks it is related to the disease. After continuing to use, she will suffer more loss of consciousness. she is transferred to the emergency ward of the hospital. According to the history of people around her about urinary infection, she is under investigation for meningitis and other causes. No finding found. After consultation with the toxicologist, a urine screen is requested and barbiturate is reported positive. Phenobarbital serum level is subsequently requested and reported. Consciousness returns with necessary treatments such as urine alkalinization. Results :In the case of the above handing over the registration to the secretary, the pharmacist's inaccuracy and lack of checking compatibility with other drugs, the inaccuracy of the second doctor in the emergency room regarding the patient's drugs and the lack of request from the family to bring the drugs drew attention. Conclusion: Swiss cheese model: In every system, there are many defects, but these defects do not always lead to errors. Defects in different parts of the system occur unexpectedly and simultaneously, and a chain of these defects leads to an accident. In other words, a single error usually does not lead to an accident, because there are other layers that play a protective role and keep patient safety.
کلمات کلیدی
phenobarbital, phenazopyridine, malpractice, Swiss cheese
