Erroneous administration of vinblastine.
This case describes a series of errors which resulted in an avoidable death of the patient. Upon being presented with the 83-year-old patient and her complaints, the physician in charge attempted to prescribe Vasolastine (a complex preparation used, for example, in treatment of angiopathy, which is administered intramuscularly once a day). Unfortunately he misspelled the name of the medicine as Vinplastyna--a non-existent preparation. When the patient's daughter went to collect the prescription from the pharmacist she was dispensed Vinblastin (vinblastine--a cytostatic medicine used, for example, in treating Hodgkin's disease, non-Hodgkin's lymphoma, chronic lymphatic leukemia and testicular cancer). The visiting community nurses administered a dose of this medicine on seven consecutive days. Upon being given the seventh dose, the patient displayed symptoms of myelophthisis, and was admitted to an Intensive Care Ward, where despite the treatment, she died.
Barzdo
Maciej
M
Department of Forensic Court and Insurance Certification, Medical University of Lodz, ul. Sedziowska 18a, 91-304, Lodz, Poland.
Zydek
Leszek
L
Smedra-Kaźmirska
Anna
A
Zgoda
Marian
M
Machała
Waldemar
W
Berent
Jarosław
J
D000369:Aged, 80 and over; D011307:Drug Prescriptions / Q000592:standards*; D017809:Fatal Outcome; D005260:Female; D006236:Handwriting; D006801:Humans; D008049:Lipase / Q000627:therapeutic use; D008084:Lipoxygenase / Q000627:therapeutic use; D008508:Medication Errors; D010593:Pharmaceutical Services / Q000592:standards; D010820:Physicians / Q000592:standards; D014747:Vinblastine / Q000506:poisoning*
D014747:Vinblastine; C029007:vasoelastine; D008084:Lipoxygenase; D008049:Lipase