Onterechte diagnose 'lithiumintoxicatie' door gebruik van bloedafnamebuizen met lithium-heparine

– In two male patients, aged 53 and 21 years, lithium intoxication was suspected. The diagnosis was apparently confirmed by blood testing (the lithium concentrations amounted to 3.68 and 1.82 mmoll, respectively). Retrospectively however it was found that blood sampling tubes with lithium-heparin as the anticoagulant had been used. No lithium intoxication was present in the patients. Clear instructions in writing are necessary to prevent this error.