Physicochemical incompatibility between tacrolimus and PVC: A preventable adverse event
DOI:
https://doi.org/10.35509/01239015.954Keywords:
Pharmacovigilance, tacrolimus, graft vs host disease, bone marrow transplantation, drug-related side effects and adverse reactions, drug incompatibility, chemical phenomena, polyvinyl chloride, phthalateAbstract
Incompatibility was identified between nasogastric tube (PVC) material and tacrolimus prescribed to a patient with Graft-versus-Host Disease (GVHD). GVHD is an immunological complication observed in 40 % to 60 % of patients receiving allogeneic hematopoietic stem cell transplantation, who require immunosuppression with tacrolimus and other management strategies such as photopheresis. The case of a patient with GVHD who avoided the risk of exposure to leachate in the reconciliation of medicines that is carried out in the pharmaceutical service is described. For causality analysis are used “5 Whys" and cause-effect diagram (Ishikawa), and thus identify opportunities for improvement in the care of these patients. The analysis of the case shows the existence of fragile interdisciplinary processes, which could be strengthened by including pharmacists in conciliation, change and adaptation of medications and thus reduce this type of adverse events in the National Cancer Institute.
Author Biographies
Jesús Ricardo Arias-Cubaque, Departamento de Farmacia, Universidad Nacional de Colombia, Bogotá D. C., Colombia.
1. Departamento de Farmacia, Universidad Nacional de Colombia, Bogotá, D. C., Colombia.
Claudia Patricia Vaca-González, Departamento de Farmacia, Universidad Nacional de Colombia, Bogotá D. C., Colombia.
1. Departamento de Farmacia, Universidad Nacional de Colombia, Bogotá, D. C., Colombia.
Ruben Heli Silva-Muñetones, Departamento de Farmacia, Universidad Nacional de Colombia, Bogotá D. C., Colombia.
1. Departamento de Farmacia, Universidad Nacional de Colombia, Bogotá, D. C., Colombia.
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