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KMID : 0357820040280010068
Korean Journal of Legal Medicine
2004 Volume.28 No. 1 p.68 ~ p.71
A Death Resulting from Inadvertent Intravenous Injection of Antidiarrheal: A Case Report.
Lee Bong-Woo

Kwon Tae-Jung
Kim Youn-Shin
Chung Nak-Eun
Choi Young-Shik
Lee Won-Tae
Abstract
Although medication errors in hospital are common, medication errors that result in death rarely occur. We report a case of inadvertent intravenous injection of SMECTA(TM), a kind of oral antidiarrheal, in a 4-year-old boy, who underwent orthopedic surgery of foot to correct congenital malformation. After this medical accident seizure suddenly developed, mental change, and disseminated intravascular coagu-lopathy followed. The diagnostic confirmation of this fatal error was made after thrombi and foreign materials were identified the histopathologic examination in the lung, as well as by analyzing the components of the antidiarrheal such as magnesium, aluminum etc. We propose to make it a rule to keep the strategies, for examples, oral liquids should not be put in Luer-lock syringes for IV administration, avoid drugs with similar names or packages form placing in the same area to reduce errors.
KEYWORD
Intravenous injection, antidiarrheal, disseminated intravascular coagulopathy
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