ENT, Head and Neck Surgery, Sri Ramachandra Medical College and Research Institute, Chennai, India.
ENT, Head and Neck Surgery, Sri Ramachandra Medical College and Research Institute, Chennai, India
BMJ Case Rep. 2020 Nov 23;13(11):e236018. doi: 10.1136/bcr-2020-236018.
The most common cause of preventable mortality and morbidity to the patient in a healthcare system is medication error. Medication errors have got a significant impact on the patient health and healthcare system. These errors are multidisciplinary and can occur at various stages of drug therapy. Physicians, nursing staff, pharmacists, hospital administration all have an important role in preventing medication errors from recurring. The most common causes include wrong patient, wrong drug prescription, look-alike sound-alike drugs, faulty drug administration, wrong dosage, drug storage, delivery problem, lack of staff, patient and physician education and failure to monitor closely. This case illustrates the importance of incorporating protocol and cross-checking before administering a drug during the procedure. Here, we discuss a case of accidental intraoral injection of xylene instead of xylocaine (local anaesthetic agent), which was a sound-alike drug that resulted in significant morbidity to the patient.
在医疗保健系统中，导致患者可预防的死亡和发病的最常见原因是用药错误。用药错误对患者的健康和医疗保健系统都有重大影响。这些错误是多学科的，可能发生在药物治疗的各个阶段。医生、护理人员、药剂师、医院管理人员在防止用药错误再次发生方面都发挥着重要作用。最常见的原因包括错误的患者、错误的药物处方、类似的药物、错误的药物给药、错误的剂量、药物储存、输送问题、人员不足、患者和医生教育以及未能密切监测。本案例说明了在给药过程中在给药前纳入协议和交叉检查的重要性。在这里，我们讨论了一个意外将二甲苯（局部麻醉剂）而非口腔内注射的案例，这是一种类似的药物，导致患者出现严重的发病。
