Clinical Pharmacology: Advances and Applications (Nov 2023)
Ipratropium Bromide/Salbutamol-Induced Acute Urinary Retention as a Result of Medication Error: A Case Report and Review of Cases in the Literature
Abstract
Mohammed Abdullah Kubas,1,2 Fahmi Y Al-Ashwal,1,3 Orwa Khaled Babattah,4 Akram Ameen Alsaqqaf4 1Department of Clinical Pharmacy and Pharmacy Practice, University of Science and Technology, Sana’a, Yemen; 2Clinical Pharmacy Department, University of Science and Technology Hospital (USTH), Sana’a, Yemen; 3Department of Clinical Pharmacy, College of Pharmacy, Al-Ayen University, Thi-Qar, Iraq; 4Urology Department, University of Science and Technology Hospital (USTH), Sana’a, YemenCorrespondence: Fahmi Y Al-Ashwal, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Science and Technology, Sana’a, Yemen, Tel +60146177642, Email [email protected]: Medication errors have the potential to cause serious toxicity and hospitalization. This case report describes a 25-year woman who suffered serious side effects and was hospitalized after receiving intravenous ipratropium bromide/salbutamol. This was due to a medication error in its preparation and administration. The caregiver diluted an intravenous antibiotic with the incorrect diluent (nebulizer solution), which led to serious toxicity, including acute urine retention and sinus tachycardia, and then resulted in patient hospitalization. A literature review of case reports was conducted to compare and identify the pattern of ipratropium/salbutamol-induced acute urinary retention. The present report underscores the importance of clinical awareness about medication-induced acute urine retention. Furthermore, it is crucial that physicians inform and educate the patients and their carers about double-checking doses and labelling before administering medication, particularly for intravenous drugs.Keywords: medication error, ipratropium bromide toxicity, acute urinary retention, parenteral administration
