A Minor Medical Error May Cause Significant Complications

Document Type : Original Article

Authors

Department of Internal Medicine, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

Abstract

Control and correct recording of both fluid intake and urinary output is a simple but an important measure in the management and treatment of patients with acute renal failure (ARF). Incorrect recording of urinary output by nurses may cause to significant complications among these patients. In this report, we report the results of misdiagnosis due to incorrect recoding of urinary output in a 28-year-old female patient with severe preeclampsia at 31 weeks of gestation who developed ARF and anuria after hysterectomy during emergency cesarean section. Computed tomography and serial ultrasonography of kidneys and urinary tract on 2, 4, 8, and 12 day after cesarean section revealed only mild hydronephrosis. Although, the patient had no urinary output, but was mistakenly, due to not emptying the urine bag daily, a nurse's record of daily urinary output of 300-350 ml/day was entered. We thought that ARF is due to acute tubular necrosis because of severe bleeding during surgery and hydronephrosis is a secondary consequence of her recent pregnancy.  After fifteen days, it was revealed that the patient had anuria and therefore our diagnosis was changed to bilateral ureteral ligation during hysterectomy, which was corrected and her renal function was normalized.

Keywords

References

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Jundishapur Scientific Medical Journal
Volume 12, Issue 1 - Serial Number 82
July and August 2013
Pages 105-109

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History

  • Receive Date: 23 September 2011
  • Revise Date: 16 January 2012
  • Accept Date: 21 January 2012

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