阿塞那平致精神分裂症患者严重肌张力障碍：因药物名称相似导致用药错误。
Asenapine-induced severe dystonia in a patient with schizophrenia: medication error due to sound-alike drug.
作者信息
Wulff Sanne, Nielsen Jimmi, Pedersen Nicolai, Nielsen Mette Ødegaard
机构信息
Unit for Complicated Schizophrenia, Copenhagen University Hospital, Region Hovedstadens Psykiatri, Glostrup, Capital Region, Denmark
Unit for Complicated Schizophrenia, Copenhagen University Hospital, Region Hovedstadens Psykiatri, Glostrup, Capital Region, Denmark.
出版信息
BMJ Case Rep. 2025 Jun 24;18(6):e264354. doi: 10.1136/bcr-2024-264354.
This case report stresses the importance of exercising caution when translating the names of prescribed drugs, especially when treating patients from abroad. We describe a young female migrant from Ukraine seeking help in the Danish mental healthcare system due to worsening psychotic symptoms. The misinterpretation of the sound-alike drugs Azapin (clozapine) and asenapine caused an acute dystonic reaction. This case illustrates various pitfalls regarding medication error. First, it uncovers a medication error due to a sound-alike drug and emphasises the importance of paying attention to national guidelines since first-line treatment can differ between countries. These factors combined increase the risk of medication error with potentially fatal consequences.
本病例报告强调了在翻译处方药名称时谨慎行事的重要性，尤其是在治疗来自国外的患者时。我们描述了一名来自乌克兰的年轻女性移民，由于精神病症状恶化，在丹麦精神卫生保健系统寻求帮助。发音相似的药物阿扎平（氯氮平）和阿塞那平的误译导致了急性肌张力障碍反应。本病例说明了用药错误的各种陷阱。首先，它揭示了因发音相似的药物导致的用药错误，并强调了关注国家指南的重要性，因为各国的一线治疗可能有所不同。这些因素加在一起增加了用药错误的风险，可能会带来致命后果。
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