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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| Autores principales: | , , , , , |
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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: |
| Sumario: | 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 |
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