A case of oxaliplatin overdose

Soloni, Pietro; Compostella, A; Carli, Modesto; Bisogno, Gianni

doi:10.1002/pbc.21952

Cited by 2 publications

(5 citation statements)

References 3 publications

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“…Other potential consequences identified included an increased requirement for monitoring (90 orders; 0.48%) and a possible reduction in therapeutic efficacy (82 orders; 0.44%) (Table ). Four potentially lethal chemotherapy errors (0.02%), involving overdoses of oxaliplatin, doxorubicin, mitoxantrone, and paclitaxel, were prevented (Table ) …”

Section: Resultsmentioning

confidence: 99%

“…Prescribing errors are common, but largely can be prevented before drug administration to the patient if appropriate safety structures are in place. Clinical pharmacists play a pivotal role in this error avoidance, designing safety structures and teaching other health care staff …”

Section: Discussionmentioning

confidence: 99%

“…Clinical pharmacists play a pivotal role in this error avoidance, designing safety structures and teaching other health care staff. 9,14,17 A combination of professional education, informatics, and financial incentives for prescription screening have been shown to improve the prescribing safety of nonsteroidal anti-inflammatory drugs and selected antiplatelet agents in primary care. 22 This approach demonstrates parallels with the successful error prevention strategy at FUMC, at which a CPOE tool for chemotherapy ordering is used and an additional clinical accuracy check is performed by a pharmacovigilance team.…”

Section: Discussionmentioning

confidence: 99%

“…Four potentially lethal chemotherapy errors (0.02%), involving overdoses of oxaliplatin, doxorubicin, mitoxantrone, and paclitaxel, were prevented ( Table 2). [17][18][19][20][21]…”

Section: Potential Clinical Implicationsmentioning

confidence: 99%

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Avoiding chemotherapy prescribing errors: Analysis and innovative strategies

Reinhardt

Otte

Eggleton

et al. 2019

Cancer

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Background At Freiburg University Medical Center, chemotherapy prescriptions are processed via a computerized physician order entry (CPOE) tool and clinically checked by a designated chemotherapy surveillance team. Any error detected is reported instantly, corrected, and prospectively recorded. The objective of the current study was to gain insight into the causes, potential consequences, and future preventability of chemotherapy prescribing errors. Methods A detailed analysis of 18,823 consecutive antineoplastic orders placed in 2013 through 2014 was performed. In cooperation with information technology (IT) specialists, the intercepted errors were analyzed for effective future prevention using IT measures. Potential error consequences were determined by case discussions between pharmacists and physicians. Results Within 24 months, a total of 406 chemotherapy prescribing errors were intercepted that affected 375 (2%) of the total orders. Errors were classified as clinically relevant in 279 of the chemotherapy orders (1.5%). In these cases, reduced therapeutic efficacy (0.44%), the need for increased monitoring (0.48%), prolonged hospital stay (0.55%), and fatality (0.02%) were avoided as potential consequences. The most efficient conventional measures for error prevention comprised checking the order history and patient’s medical record, and a detailed knowledge of chemotherapy protocols. Of all the errors analyzed, 61% would be avoided through further software development. The improvements identified are implemented through a validated next‐generation CPOE tool. Conclusions The upgraded CPOE tool can be shared across other hospitals to raise safety standards and spread potential benefits across a wider patient population. The current analysis also highlighted that approximately 30% to 40% of errors cannot be avoided electronically. Therefore, pharmacovigilance initiatives remain indispensable.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…Four potentially lethal chemotherapy errors (0.02%), involving overdoses of oxaliplatin, doxorubicin, mitoxantrone, and paclitaxel, were prevented ( Table 2). [17][18][19][20][21]…”

Section: Potential Clinical Implicationsmentioning

confidence: 99%

See 2 more Smart Citations

Avoiding chemotherapy prescribing errors: Analysis and innovative strategies

Reinhardt

Otte

Eggleton

et al. 2019

Cancer

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show abstract

“…The cases of overdose of the most signalled chemotherapeutic drugs concern methotrexate, cisplatin, oxaliplatin, imatinib, and vincristine [12][13][14][15][16][17][18] . Although fatal events are rare, the systemic toxic effects documented by the presented case highlight the fact that the activities of the health care staff involved in the chemotherapeutic treatment are burdened by potentially lethal risks for patients.…”

Section: Discussionmentioning

confidence: 99%

An unusual fatal case of overdose of Vinblastine and review of literature

Spagnolo

Mondello

Cardia

et al. 2016

Australian Journal of Forensic Sciences

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The pharmacological treatment of neoplasia is based on the use of chemotherapeutic substances. Chemotherapeutic agents can cause acute and chronic toxicity even at therapeutic doses. For this reason their overdose puts a patient's life at severe risk. This work presents an unusual fatal case of overdose subsequent to an accidental massive administration of Vinblastine (90 mg instead of 9 mg), slow bolus (five minutes), to a 33-yearold woman who suffered from Hodgkin's Lymphoma. The administration of the massive dose was due to a transcription error of the therapeutic treatment plan and miscommunication between the health professionals which caused the use of the wrong dose. The forensic investigation showed the systemic macroscopic and histological changes due to the toxic effect of Vinblastine on the body, by offering a realistic example of the microscopic tissue changes caused by the antineoplastic agent to different organs. Such evidence shows the importance of being very accurate when writing the therapeutic treatment plans and of counting on adequately-trained health care staff.

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A case of oxaliplatin overdose

Cited by 2 publications

References 3 publications

Avoiding chemotherapy prescribing errors: Analysis and innovative strategies

Avoiding chemotherapy prescribing errors: Analysis and innovative strategies

An unusual fatal case of overdose of Vinblastine and review of literature

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