title: Fatality involving vinblastine overdose as a result of a complex medical error.
abstract: The purpose of the study is a presentation of a fatal case involving an 83-year-old woman, who died due to an overdose of vinblastine-a cytostatic agent of a vinca alkaloid employed in cancer chemotherapy. The postmortem investigation included an autopsy and histological examination, as well as a toxicological analysis of post-mortem specimens collected in the course of autopsy. The authors performed a toxicological assessment of vinblastine employing liquid chromatography-atmospheric pressure chemical ionization-tandem mass spectrometry (LC-MS-MS-APCI). The determined vinblastine concentration levels amounting to 29 ng/g in blood and 52.5 ng/g in liver were in a considerable excess of values encountered in patients on chemotherapy using the drug. The fatality was investigated in the context of medical error. In the described case, the erroneous and medically unjustified administration of vinblastine was identified by a series of unfortunate events involving as many as three acting consecutively individuals: a physician, a pharmacist and a nurse. The report may thus document the clinical course of vinblastine poisoning along with postmortem changes resulting from the drug action.
authors.affiliation: Department of Toxicology, Institute of Forensic Medicine, Collegium Medicum, Jagiellonian University, 16 Grzegórzecka St., Krakow, Poland. mpklys@cyf-kr.edu.pl
authors.forename: Małgorzata
authors.initials: M
authors.lastname: Kłys
authors.forename: Tomasz
authors.initials: T
authors.lastname: Konopka
authors.forename: Mariusz
authors.initials: M
authors.lastname: Scisłowski
authors.forename: Piotr
authors.initials: P
authors.lastname: Kowalski
mesh_terms: D000063:Accidents, Traffic; D000369:Aged, 80 and over; D000972:Antineoplastic Agents, Phytogenic / Q000493:pharmacokinetics / Q000506:poisoning*; D001344:Autopsy; D002138:Calibration; D004348:Drug Labeling; D062787:Drug Overdose; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007202:Indicators and Reagents; D007869:Leg Injuries / Q000150:complications; D008049:Lipase / Q000627:therapeutic use; D008084:Lipoxygenase / Q000627:therapeutic use; D008099:Liver / Q000737:chemistry / Q000378:metabolism; D019300:Medical Errors; D014747:Vinblastine / Q000493:pharmacokinetics / Q000506:poisoning*
chemical_list: D000972:Antineoplastic Agents, Phytogenic; D007202:Indicators and Reagents; D014747:Vinblastine; C029007:vasoelastine; D008084:Lipoxygenase; D008049:Lipase