一例医护耦合性差错药物过敏案例引起的护理查对制度的思考  

Thinking about the nursing check system caused by a case of drug allergy caused by medical coupling error

作　　者：宋庆华[1] Song Qinghua(Department of ENT,Weihai Hospital District,970 Hospital of the joint service support force of the people's Liberation Army,Shandong,Weihai,264200,China)

机构地区：[1]中国人民解放军联勤保障部队第970医院威海院区,山东威海264200

出　　处：《中国医学文摘（耳鼻咽喉科学）》2020年第1期60-61,共2页Chinese Medical Digest(Otorhinolaryngology)

摘　　要：患者男性,72岁,为行白内障手术于2019年12月2日由心内科转入眼科,主诉:苯巴比妥过敏,护士遂在八处护理文书处做好标记,并告知主管医生,经过充分的术前检查准备,于入科后第三天准备在表麻下行左眼白内障超声乳化及折叠人工晶体植入术,提前一天下达医嘱:鲁米那钠60毫克手术前一天睡前,手术当日术前口服。此药患者前一晚未服,手术当日8:00,患者自行口服鲁米那钠60毫克,手术顺利,10:00患者出手术间时即感觉手指肿胀、瘙痒,经查为鲁米那钠过敏,立即请皮肤科会诊,给予盐水100毫升+地米5毫克静滴一次,每日口服一片西替利嗪片,连续三天,患者过敏症状缓解,无加重,第四天突然出现手足部紫红色斑块,部分出现小水泡,并持续加重,中大型水泡相继出现,最大直径可达六厘米,足部为重,患者手指肿胀明显,足部疼痛,不敢下地行走。立即邀请会诊,积极按照指导进行相应用药、皮肤处置,同时安慰病人,精心护理,8天后病人恢复良好,给予出院。A 72 year old male patient was transferred from cardiology department to ophthalmology department on December 2,2019 for cataract surgery.The main complaint was:Phenobarbital allergy.The nurse then made marks at eight nursing documents and informed the doctor in charge.After sufficient preoperative examination preparation,he was ready to undergo phacoemulsification and foldable intraocular lens implantation in the left eye under topical anesthesia one day in advance Tianxiada doctor’s advice:60 mg of lumina sodium was taken orally one day before operation before going to bed.The patient didn’t take this medicine the night before.At 8:00 on the day of operation,the patient took 60 mg of lumina sodium by himself.The operation was successful.At 10:00,the patient felt swelling and itching in his fingers when he left the operation room.He was found to be allergic to lumina sodium.He immediately asked the dermatologist for consultation.He was given 100ml of salt water+5mg of Demeter by intravenous drip once.He took one cetirizine tablet daily.For three consecutive days,the patient’s allergic symptoms were relieved,On the fourth day,there were purplish red plaques on the hands and feet,some small blisters,and continued to increase.Large and medium blisters appeared one after another,with a maximum diameter of up to 6cm.The feet were heavy.The patient’s fingers were swollen obviously,and the feet were painful,so he dared not walk down.Immediately invite consultation,actively carry out corresponding medication and skin treatment according to the guidance,comfort the patient and take careful care of them.After 8 days,the patient recovers well and is discharged from the hospital.

关 键 词：耦合性差错(Coupling error) 过敏(Allergy) 查对制度(Checking system) 

分 类 号：R47[医药卫生—护理学]