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Advances in dermatology and venereology Acta Dermato-Venereologica
Generalized Bullous Fixed Drug Eruption Following Metamizole ( Re- ) Exposure : A Medical Error-analytic Case Study
Peter ELSNER 1 and Maja MOCKENHAUPT 2
1
Department of Dermatology , University Hospital Jena , Erfurter Str . 35 , DE-07743 Jena , and 2 Department of Dermatology , Dokumentationszentrum schwerer Hautreaktionen , University Freiburg – Medical Center , Freiburg , Germany . E-mail : elsner @ derma-jena . de Accepted Nov 13 , 2017 ; Epub ahead of print Nov 14 , 2017
As the Institute of Medicine ’ s report “ To err is human ” showed ( 1 ), learning from errors is of utmost importance to prevent their recurrence . For this purpose , errorreporting systems have been used in aviation for many years with the positive effect of reducing pilot errors ( 2 ). Patient safety in medicine may benefit from similar error-analytic case studies ( 3 ).
We report here a case of generalized bullous fixed drug eruption ( GBFDE ) in a 68-year-old man following repeated ( re- ) exposure to metamizole due to a sequence of clinical errors .
CASE REPORT
The patient was treated as an emergency in a department of surgery for acute occlusion of the left femoral artery by arterial thrombectomy . Despite a history of allergy to metamizole and penicillin documented on the patient ’ s admission form , he received analgesia with metamizole and perioperative antibiosis with amoxicillin . When he developed generalized exanthema , a fixed drug eruption was diagnosed by a consulting dermatologist . In the referring letter to his general practitioner ( GP ), the drug reaction and the known allergy to metamizole and penicillin were mentioned , and an allergological work-up was recommended . No allergy passport was issued , and no subsequent action was taken by the GP .
Four years later , the patient was re-admitted to the emergency department of the same hospital , with severe abdominal pain , fever , malaise and diarrhoea , under suspicion of acute cholangitis . In his admission papers , only allergy to penicillin was documented . Due to the patient ’ s serious condition , he could not be interviewed , but his wife informed the attending nurses about his allergies . Nevertheless , the patient was treated with metamizole , butylscopolamin , ciprofloxacin , and metronidazole for 2 days . On the second day , he developed a generalized erythematous eruption that was diagnosed and treated as “ sunburn ” by the treating gastroenterologists since the patient had been in the sun for a prolonged time before admission . The lesions spread and turned bullous , and the patient was transferred to the Department of Dermatology with a diagnosis of toxic epidermal necrolysis . On the basis of history , clinical findings and the results of a biopsy a final diagnosis of GBFDE was made by the Documentation Center for Severe Skin Reactions . Following systemic therapy with glucocorticosteroids and topical antiseptic treatment , the patient recovered with only minor scarring and pigmentary changes .
DISCUSSION
GBFDE is characterized by acute skin lesions , presenting with either generalized oval , egg-sized , brownishviolaceous macules or patches and subsequent blisters , which are clearly demarcated from healthy skin , or with diffuse erythema subsequently showing flaccid blisters ( 4 ). Mucous membranes are rarely involved . However , recurrences may lead to more widespread skin detachment and therefore to a more severe disease course ( 4 ).
The occurrence of medical errors in complex organizations is explained by Reason ’ s system model ( 5 ). Several barrier layers may prevent errors , but holes may remain . When several holes ( as in a “ Swiss cheese ”) coincide , the barriers are ineffective and an error occurs . The causes of barrier breakdown are active errors by caregivers and latent conditions ( errors of and in the organization ), which increase the probability of errors of the responsible persons . Damage is therefore the result of a complex interaction of different causes .
In the present case , the serious cutaneous drug reaction was probably due to the administration of metamizole , with the following error-chain : ( i ) despite a known allergy to metamizole and penicillin , the patient had been treated with both drugs at the Department of Surgery , leading to a fixed drug eruption ; ( ii ) the recommendation for an allergological work-up was disregarded by the GP ; ( iii ) no allergy passport was issued , and no alternative medication was recommended . An allergy passport is an essential safety measure , especially in case of emergency medical treatment , in order to avoid the re-administration of suspected allergens . ( iv ) On re-admission to the emergency department , an incomplete allergy history was taken , and the information provided by the patient ’ s wife ’ s was disregarded , leading to renewed exposure to metamizole . ( v ) When the patient developed a rash , this was not fully investigated , but was treated under a false diagnosis . Discontinuation of the causal agent and appropriate treatment were thus delayed .
Considering the significant mortality of 22 % in elderly patients with extensive GBFDE ( 6 ), avoidance of unintentional re-exposure to suspected drugs must be assured by a functioning clinical safety culture ( 7 ) to which error-analytic studies may contribute significantly . doi : 10.2340 / 00015555-2840 Acta Derm Venereol 2018 ; 98 : 376 – 377
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2018 Acta Dermato-Venereologica .