由于药房复合错误导致的儿童克洛尼丁过量服用和调查疑似复合错误的初步资料
Brian Patrick Murray1, Matthew David Sheridan2, Hannah Hays3
1Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA bpatmurray@gmail.com.
一名儿科患者因药房的复合错误而经历了严重的克洛尼丁过量,导致精神状态变化和性. 这一案例凸显了调查儿科过量用药的药房错误的重要性.
科学领域:
- 儿童紧急医疗
- 临床药房
- 毒理学
背景情况:
- 克隆丁过量服用可能会对儿童产生显著的毒性.
- 药房的复合错误可能导致意外的药物过量.
研究的目的:
- 报告一个严重的儿童克隆过量病例,
- 突出涉嫌复合错误的临床指标和调查步骤.
主要方法:
- 一个2-5岁的男性出现过量症状的病例报告.
- 对药房配制程序和国家药房局调查结果的审查.
主要成果:
- 由于使用粉末而不是药片,意外发生了1000倍的克隆过量.
- 患者出现精神状态变化,心肌梗塞,高血压和麻性,需要接受ICU治疗并安置鼻胃管.
结论:
- 药房复合错误是儿童过量使用的关键因素.
- 临床医生应获得详细的药物历史,以确定潜在的复合错误.
- 在药物错误引起的不良事件中,及时调查和管理至关重要.
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