title: Fatal cisplatin overdose in the treatment of mediastinal lymphoma with the ESHAP regimen - analysis of the causes of the adverse drug event.
abstract: BACKGROUND
  Cisplatin is a chemotherapeutic agent that may cause acute (or chronic) organ toxicity. As there is no antidote, prevention of adverse drug events is essential for patients' safety.
  
  
  METHODS
  The authors present the case of a 33-year-old woman treated for lymphoma with the ESHAP regimen, who died of an overdose of cisplatin. The drug was administered at a rate 4 times greater than the recommended maximum dose. The first symptom of overdose - partial hearing loss - appeared after administration of the last dose of the drug on day 4 of the chemotherapy course. The initiation of intensive treatment with plasmapheresis and dialyses was ineffective. The patient died 18 days after receiving the last dose of cisplatin. The medication schedule had been prepared by an inexperienced physician. The information on cisplatin dosage had been sourced from a vague instruction in a clinical oncology manual: '100 mg/m(2) continuous i.v. infusion d.1-4'. The instruction was misinterpreted. The patient was given 100 mg/m(2) on each of the 4 days of the treatment.
  
  
  CONCLUSIONS
  Special care must be taken when preparing a medication schedule; the treatment must be checked by an experienced physician and verified by the nursing staff. The patient should be monitored for symptoms of cisplatin intoxication.
authors: Department of Forensic Medicine, Wroclaw Medical University, Poland.
authors: Tomasz
authors: T
authors: Jurek
authors: Marta
authors: M
authors: Rorat
authors: Piotr
authors: P
authors: Dys
authors: Barbara
authors: B
authors: Swiatek
mesh_terms: D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage* / Q000506:poisoning*; D002945:Cisplatin / Q000008:administration & dosage / Q000506:poisoning*; D003561:Cytarabine / Q000008:administration & dosage / Q000506:poisoning; D062787:Drug Overdose / Q000209:etiology*; D005047:Etoposide / Q000008:administration & dosage / Q000506:poisoning; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008223:Lymphoma / Q000150:complications / Q000188:drug therapy*; D008479:Mediastinal Neoplasms / Q000150:complications / Q000188:drug therapy*; D008508:Medication Errors / Q000009:adverse effects*; D008775:Methylprednisolone / Q000008:administration & dosage / Q000506:poisoning
chemical_list: D003561:Cytarabine; D005047:Etoposide; D002945:Cisplatin; D008775:Methylprednisolone