A Minor Medical Error May Cause Significant Complications

Document Type : Original Article


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


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.


1- Lameire, N, Van Biesen, W, Vanholder R. Acute renal failure. Lancet 2005;365:417.
2-Liano F, Pascual J. Epidemiology of acute renal failure: A prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group. Kidney Int 1996;50(3):811-8.
3-Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8(4):R204-12.
4-Esson ML, Schrier RW. Diagnosis and treatment of acute tubular necrosis. Ann Intern Med 2002;137(9):744-54.
5-Liangos O, Wald R, O`Bell JW, Price L, Pereira BJ, Jaber BL. Epidemiology and outcomes of acute renal failure in hospitalized patients: A national survey. Clin J Am Soc Nephrol 2006;1(1):43-51.
6-Honda N, Hishida A. Pathophysiology of experimental nonoliguric acute renal failure. Kidney Int 1993;43(3):513-21.
7-Webb JA. Regular review: Ultrasonography in the diagnosis of urinary tract obstruction. BMJ 1990;301:944.
 8-Platt JF, Rubin JM, Ellis JH. Acute renal obstruction: Evaluation with intrarenal duplex Doppler and conventional US. Radiology 1993;186(3):685-8.