Patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of Trimethoprim / Sulfamethoxazole
A fundamental aspect in patient safety (SP) is related to adverse drug reactions (RAM) and medication errors (ME) and, although there are no risk-free medications, a large percentage of these are preventable. Case report. Female patient, 32 years. On 06/16/2018, she enters the guard presenting urtic...
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| Formato: | Artículo revista |
| Lenguaje: | Español |
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Universidad Nacional Córdoba. Facultad de Ciencias Médicas. Secretaria de Ciencia y Tecnología
2019
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| Materias: | |
| Acceso en línea: | https://revistas.unc.edu.ar/index.php/med/article/view/25735 |
| Aporte de: |
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I10-R327-article-25735 |
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ojs |
| institution |
Universidad Nacional de Córdoba |
| institution_str |
I-10 |
| repository_str |
R-327 |
| container_title_str |
Revista de la Facultad de Ciencias Médicas de Córdoba |
| language |
Español |
| format |
Artículo revista |
| topic |
patient safety adverse drug reactions medication errors trimethoprim/sulfamethoxazole trimetoprima/sulfametoxazol reacción adversa error de medicación |
| spellingShingle |
patient safety adverse drug reactions medication errors trimethoprim/sulfamethoxazole trimetoprima/sulfametoxazol reacción adversa error de medicación González, AC Godoy Rossi, LJ Carnielli, C Culasso, AF Bessone, L Romañuk, CB Patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of Trimethoprim / Sulfamethoxazole |
| topic_facet |
patient safety adverse drug reactions medication errors trimethoprim/sulfamethoxazole trimetoprima/sulfametoxazol reacción adversa error de medicación |
| author |
González, AC Godoy Rossi, LJ Carnielli, C Culasso, AF Bessone, L Romañuk, CB |
| author_facet |
González, AC Godoy Rossi, LJ Carnielli, C Culasso, AF Bessone, L Romañuk, CB |
| author_sort |
González, AC |
| title |
Patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of Trimethoprim / Sulfamethoxazole |
| title_short |
Patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of Trimethoprim / Sulfamethoxazole |
| title_full |
Patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of Trimethoprim / Sulfamethoxazole |
| title_fullStr |
Patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of Trimethoprim / Sulfamethoxazole |
| title_full_unstemmed |
Patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of Trimethoprim / Sulfamethoxazole |
| title_sort |
patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of trimethoprim / sulfamethoxazole |
| description |
A fundamental aspect in patient safety (SP) is related to adverse drug reactions (RAM) and medication errors (ME) and, although there are no risk-free medications, a large percentage of these are preventable.
Case report. Female patient, 32 years. On 06/16/2018, she enters the guard presenting urticaria, erythematous and pruritic macules in the trunk and upper extremities, facial edema, diarrhea and vomiting with 3 months of evolution, epigastric abdominal pain, without fever and malaise. dexamethasone and diphenhydramine are administered every 8 h, for 3 days. The case is diagnosed as "allergic reaction" and discharge is granted. On 07/23/2018 she re-enters, presenting acute non-surgical and distended abdomen, nausea, fever and generalized paleness. On 07/24/2018, she is diagnosed as B24X(+) stage C3 and begins antiretroviral treatment + trimethoprim/sulfamethoxazole (TMS/SMX) 800/160 mg three times/week and azithromycin 500mg 3 tablets/saturday. On the second day of treatment, she return with severe muscle aches, cramps, dizziness, dark urine, clear stools, swollen and painful mammary glands. It is suspended (TMS/SMX) and dapsona is administered 100 mg/day. On 02/21/2019, she is admitted for gastrointestinal problems and abdominal distention. Infectious diarrhea is diagnosed and TMS/SMX is administered, and she manifested again the symptoms presented in 2018.
The pharmacist warns the doctor of this episode and this treatment is permanently discontinued. Within the first days of HIV acquisition, a transient disease, sometimes symptomatic, associated with high levels of virus replication and a rapid fall of T CD4 lymphocytes occurs. This may explain the symptoms presented on 06/16/2018. The pharmacist performed an analysis of the medications administered to the patient discarding interactions between them. Through the imputation, the RAM was cataloged as “definite” for TMS/SMX due to the temporal sequence and the re-exposure to the medication and, in addition, warned about the ME caused in the prescription since the doctor did not notice the symptoms suffered in the first administration of this medicine.
In this context, it can be concluded that the pharmacist's intervention plays a fundamental role to guarantee the safe, effective and efficient use of medications, thus contributing to the SP |
| publisher |
Universidad Nacional Córdoba. Facultad de Ciencias Médicas. Secretaria de Ciencia y Tecnología |
| publishDate |
2019 |
| url |
https://revistas.unc.edu.ar/index.php/med/article/view/25735 |
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I10-R327-article-257352024-08-27T18:26:10Z Patient safety in the use of medications: a case report of adverse drug reaction and medication error due to administration of Trimethoprim / Sulfamethoxazole Seguridad del paciente en el uso de medicamentos: reporte de un caso de reacción adversa y error de medicación por administración de Trimetoprima/Sulfametoxazol González, AC Godoy Rossi, LJ Carnielli, C Culasso, AF Bessone, L Romañuk, CB patient safety adverse drug reactions medication errors trimethoprim/sulfamethoxazole trimetoprima/sulfametoxazol reacción adversa error de medicación A fundamental aspect in patient safety (SP) is related to adverse drug reactions (RAM) and medication errors (ME) and, although there are no risk-free medications, a large percentage of these are preventable. Case report. Female patient, 32 years. On 06/16/2018, she enters the guard presenting urticaria, erythematous and pruritic macules in the trunk and upper extremities, facial edema, diarrhea and vomiting with 3 months of evolution, epigastric abdominal pain, without fever and malaise. dexamethasone and diphenhydramine are administered every 8 h, for 3 days. The case is diagnosed as "allergic reaction" and discharge is granted. On 07/23/2018 she re-enters, presenting acute non-surgical and distended abdomen, nausea, fever and generalized paleness. On 07/24/2018, she is diagnosed as B24X(+) stage C3 and begins antiretroviral treatment + trimethoprim/sulfamethoxazole (TMS/SMX) 800/160 mg three times/week and azithromycin 500mg 3 tablets/saturday. On the second day of treatment, she return with severe muscle aches, cramps, dizziness, dark urine, clear stools, swollen and painful mammary glands. It is suspended (TMS/SMX) and dapsona is administered 100 mg/day. On 02/21/2019, she is admitted for gastrointestinal problems and abdominal distention. Infectious diarrhea is diagnosed and TMS/SMX is administered, and she manifested again the symptoms presented in 2018. The pharmacist warns the doctor of this episode and this treatment is permanently discontinued. Within the first days of HIV acquisition, a transient disease, sometimes symptomatic, associated with high levels of virus replication and a rapid fall of T CD4 lymphocytes occurs. This may explain the symptoms presented on 06/16/2018. The pharmacist performed an analysis of the medications administered to the patient discarding interactions between them. Through the imputation, the RAM was cataloged as “definite” for TMS/SMX due to the temporal sequence and the re-exposure to the medication and, in addition, warned about the ME caused in the prescription since the doctor did not notice the symptoms suffered in the first administration of this medicine. In this context, it can be concluded that the pharmacist's intervention plays a fundamental role to guarantee the safe, effective and efficient use of medications, thus contributing to the SP Un aspecto fundamental en la seguridad del paciente (SP) está relacionado a las reacciones adversas a medicamentos (RAM) y los errores de medicación (EM) y, aunque no hay medicamentos exentos de riesgo, un gran porcentaje de éstos son evitables. Presentación del caso. Paciente femenina, 32 años. El 16/06/2018 ingresa a la guardia presentando urticaria, máculas eritematosas y pruriginosas en tronco y extremidades superiores, edema facial, diarrea y vómitos con 3 meses de evolución, dolor abdominal epigástrico, sin fiebre y malestar general. Se administra Dexametasona y Difenhidramina cada 8h, por 3 días. El cuadro es diagnosticado como “reacción alérgica” y se otorga el alta. El 23/07/2018 reingresa, presentando abdomen agudo no quirúrgico y distendido, naúseas, fiebre y palidez generalizada. El 24/07/2018 es diagnosticada como B24X (+) estadio C3 e inicia tratamiento antirretroviral+Trimetoprima/Sulfametoxazol (TMS/SMX) 800/160mg tres veces/semana y Azitromicina 500mg 3 comprimidos/sábado. Al segundo día de tratamiento, regresa con dolores musculares intensos, calambres, mareos, orina oscura, heces claras, glándulas mamarias inflamadas y dolorosas. Se suspende (TMS/SMX) y se administra Dapsona 100mg/día. El 21/02/2019, es internada por problemas gastrointestinales y distención abdominal. Se diagnostica diarrea infecciosa y se administra TMS/SMX, maniféstandosé nuevamente los síntomas presentados en 2018. La farmacéutica advierte al médico de este episodio y se suspende definitivamente este tratamiento. Dentro de los primeros días de la adquisición del VIH ocurre una enfermedad transitoria, a veces sintomática, asociada a altos niveles de replicación del virus y a una rápida caída de los linfocitos TCD4. Esto puede explicar los síntomas presentados el 16/06/2018. La farmacéutica realizó un análisis de los medicamentos administrados a la paciente descartando interacciones entre ellos. Mediante la imputación, la RAM fue catalogada como “probada” para TMS/SMX debido a la secuencia temporal y a la re-exposición al medicamento y, además advirtió sobre el EM provocado en la prescripción dado que el médico no se percató de los síntomas sufridos en la primera administración de este medicamento. En este contexto, se puede concluir que la intervención del farmacéutico es clave para garantizar el uso seguro, efectivo y eficiente de los medicamentos, aportando así a la SP Universidad Nacional Córdoba. Facultad de Ciencias Médicas. Secretaria de Ciencia y Tecnología 2019-10-11 info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion application/pdf https://revistas.unc.edu.ar/index.php/med/article/view/25735 Revista de la Facultad de Ciencias Médicas de Córdoba.; 2019: Suplemento JIC XX Revista de la Facultad de Ciencias Médicas de Córdoba; 2019: Suplemento JIC XX Revista da Faculdade de Ciências Médicas de Córdoba; 2019: Suplemento JIC XX 1853-0605 0014-6722 10.31053/1853.0605.v76.nSuplemento spa https://revistas.unc.edu.ar/index.php/med/article/view/25735/27424 Derechos de autor 2019 Universidad Nacional de Córdoba https://creativecommons.org/licenses/by-nc/4.0 |