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Case report: cisplatin preparation error; patient management and morbidity

¹ Pharmacy Department, Hospital General de Ciudad Real, Ciudad Real, Spain
² Pharmacy Department, University Hospital Dr Peset, Valencia, Spain, Department of Pharmacy and Pharmaceutics, University of Valencia, Spain
³ Oncology Unit, University Hospital Dr Peset, Valencia, Spain

^* To whom correspondence should be addressed.

	Abstract

Introduction. 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.

Setting. We report a 57-year-old man with head and neck cancer who mistakenly received 180 mg/m² 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.

Result. 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.

Key Words: Overdose; cisplatin; management; toxicity; medication error; morbidity

First published on March 20, 2009, doi:10.1177/1078155209103657
This version was published on August 26, 2009


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