Minor medical error may cause to significant complications

Control and correct recordation of fluid intake and urinary output is a simple but an important measure in the management and treatment of patients with acute renal failure (ARF) and non-correct recordation of urinary output by nurse may cause to significant complications among these patients. The patient was a 28-yaer-old woman 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 in 2، 4، 8، and 12 day after cesarean section revealed only mild hydronephrosis. Although، the patient has not been any urinary output، but unfortunately the recoded urinary output by nurses was 300-350 ml/day due to urinary bag has not been empted in the end of each day. We thought that ARF is due to acute tubular necrosis because of severe bleeding during surgery and hydronephrosis is secondary to recent pregnancy. After fifteen days، it was revealed that the patient had anuria during this period and therefore our diagnosis was changed to bilateral ureteral ligation during hysterectomy and renal function improved after correction of ureteral obstruction