Cisplatin preparation error; patient management and morbidity.
BACKGROUND
Antineoplastic drug therapy errors represent a high iatrogenic potential due to antineoplastic drugs narrow therapeutic ranges and the complexity of chemotherapy regimens that may increase the risk of morbidity and mortality for oncology patients.


METHODS
We report a 57-year-old man with head and neck cancer who mistakenly received 180 mg/ m(2) of cisplatin overdose despite the safety measures and validations carried out during preparation. The patient developed moderate nausea and vomiting, acute renal failure, hearing difficulty (tinnitus), and severe myelodepression. PATIENT MANAGEMENT: Prophylactic and symptomatic treatments were applied in order to prevent and correct toxicity during the 9 days stay at hospital.


RESULTS
He recovered with mild tinnitus and mild renal impairment as the only sequelae. This case presents a hospital stay and treatment quite different to others used to reverse all cisplatin overdose toxicity and it shows the benefits of prompt management.
Vila-Torres
E
E
Pharmacy Department, Hospital General de Ciudad Real, Ciudad Real, Spain. vila_eli@gva.es
Albert-Marí
A
A
Almenar-Cubells
D
D
Jiménez-Torres
N V
NV
D058186:Acute Kidney Injury / Q000139:chemically induced / Q000628:therapy; D000328:Adult; D000970:Antineoplastic Agents / Q000008:administration & dosage* / Q000009:adverse effects* / Q000627:therapeutic use; D001855:Bone Marrow Diseases / Q000139:chemically induced / Q000628:therapy; D002945:Cisplatin / Q000008:administration & dosage* / Q000009:adverse effects* / Q000627:therapeutic use; D004339:Drug Compounding; D062787:Drug Overdose; D006258:Head and Neck Neoplasms / Q000188:drug therapy; D006801:Humans; D008297:Male; D019300:Medical Errors; D009325:Nausea / Q000139:chemically induced / Q000188:drug therapy; D014012:Tinnitus / Q000139:chemically induced
D000970:Antineoplastic Agents; D002945:Cisplatin