一位84 歲女性病人因為泌尿道感染入院， 給與經驗性抗生素ertapenem 治療5 天， 因為感染情況未改善， 改以抗生素imipenem/cilastatin (1,000 mg Q8H intravenous drip [IVD]) 做後續治療，使用兩個劑量後病人癲癇發作，給與抗癲癇藥物levetiracetam 和lorazepam 治療1 天後症狀消除。依藥物不良反應相關性Naranjo score 評分，此案例「可能」為imipenem/cilastatin 未依照病人體重和腎功能調整劑量造成癲癇發作。雖然藥師在第一時間有提醒處方之住院醫師應調整，但醫師認為病人臨床感染問題應優先控制而拒絕更改劑量。藥師也未進一步與主治醫師溝通此問題，導致病人出現可預防副作用癲癇的發生。為了病人用藥安全，應該在醫療人員之間建立一個更好的溝通平臺。

An 84-year-old woman was admitted to the emergency department for suspected urinary tract infection. An empirical antibiotic of ertapenem was given for 5 days and then shifted to intravenous imipenem/cilastatin (1,000 mg every eight hours) due to poor clinical response. After two doses of imipenem/cilastatin, the patient developed a seizure attack, which was controlled after the administration of levetriactam and lorazepam for 1 day. According to the algorithm of Naranjo score, this adverse drug reaction was graded as “probable”. That is, the seizure attack was probably associated with the unadjusted doses of imipenem/cilastatin. Although the clinical pharmacist had informed the resident doctor about this concern, further follow up or communication was not performed. Unfortunately, patient experienced the preventable adverse effect. It is essential to establish an efficient communication platform between healthcare professionals to improve patient safety.