Ipratropium Bromide/Salbutamol-Induced Acute Urinary Retention as a Result of Medication Error: A Case Report and Review of Cases in the Literature

Medication errors have the potential to cause serious toxicity and hospitalization. This case report describes a 25-year woman who suffered serious side effects and was hospitalized after receiving intravenous ipratropium bromide/salbutamol. This was due to a medication error in its preparation and administration. The caregiver diluted an intravenous antibiotic with the incorrect diluent (nebulizer solution), which led to serious toxicity, including acute urine retention and sinus tachycardia, and then resulted in patient hospitalization. A literature review of case reports was conducted to compare and identify the pattern of ipratropium/ salbutamol-induced acute urinary retention. The present report underscores the importance of clinical awareness about medication-induced acute urine retention. Furthermore, it is crucial that physicians inform and educate the patients and their carers about double-checking doses and labelling before administering medication, particularly for intravenous drugs.