Fatality involving vinblastine overdose as a result of a complex medical error

Cancer Chemotherapy and Pharmacology

Volumn 59, Issue 1, 2007, Pages 89-95

  Kłys, Małgorzata ^a   Konopka, Tomasz ^a   Ścisłowski, Mariusz ^a   Kowalski, Piotr ^a  

^a JAGIELLONIAN UNIVERSITY   (Poland)

Author keywords

Atmospheric pressure chemical ionization mass spectrometry; Liquid chromatography; Medical error; Overdosage; Vinblastine

Indexed keywords

AMIKACIN; CEFOTAXIME; CYTOSTATIC AGENT; DOPAMINE; METRONIDAZOLE; NORADRENALIN; NYSTATIN; RECOMBINANT GRANULOCYTE COLONY STIMULATING FACTOR; VASOLASTINE; VINBLASTINE; VINCA ALKALOID; VINCRISTINE;

AGED; ARTICLE; AUTOPSY; BONE MARROW APLASIA; CANCER CHEMOTHERAPY; CASE REPORT; DRUG BLOOD LEVEL; DRUG OVERDOSE; FEMALE; HISTOLOGY; HUMAN; LEUKOCYTOSIS; LIQUID CHROMATOGRAPHY; MALAISE; MEDICAL ERROR; MYALGIA; NURSE; PHARMACIST; PHYSICIAN; PRIORITY JOURNAL; SEPSIS; TANDEM MASS SPECTROMETRY;

ACCIDENTS, TRAFFIC; AGED, 80 AND OVER; ANTINEOPLASTIC AGENTS, PHYTOGENIC; AUTOPSY; CALIBRATION; DRUG LABELING; FATAL OUTCOME; FEMALE; HUMANS; INDICATORS AND REAGENTS; LEG INJURIES; LIPASE; LIPOXYGENASE; LIVER; MEDICAL ERRORS; OVERDOSE; VINBLASTINE;

EID: 33751282952     PISSN: 03445704     EISSN: None     Source Type: Journal    
DOI: 10.1007/s00280-006-0246-1     Document Type: Article

References (20)

1. Chae L, Moon HS, Kim SC (1998) Overdose of vincristine: experience with patient. J Korean Med Sci 13/3:334-348
2. Conter V, Rabbone ML, Jankovic M, Fraschini d, Corbetta A, Pacheco C, D'Angelo P, Masera G (1991) Overdose of vinblastine in a child with Langerhans'cell histiocytosis: toxicity and salvage therapy. Pediatr Hematology Oncol 8(2):165-169
3. Kaufman IA, Kung FH, Koenig HM, Giammona ST (1976) Overdosage with vincristine. J Pediatr 89/4:671-674
4. Kosmidis HV, Bouhoutsou DO, Varvoutsi MC, Papadatos J, Stefanidis CG, Vlachos P, Scardoutsou A, Kostakis A (1991) Vincristine overdose: experience with 3 patients. Pediatr Hematology Oncol 8/2:171-178
5. Kostowski W, Herman Z (2005) Farmakologia. Podstawy farmakoterapii. PZWL, Warszawa
6. Lau G (1996) Accidental intraventricular vincristine administration : an avoidable iatrogenic death. Med Sci Law 36/3:263-265
7. Maeda K, Ueda M, Ohtaka H, Koyama Y, Ohgami M, Miyazaki H (1987) A massive dose of vincristine. Jpn J Clin Oncol 17/3:247-253
8. Manelis J, Freudlich E, Ezekiel E, Doron J (1982) Accidental intrathecal vicristine administration. Report of a case. J Neurol 228/3:209-213
9. Marek Z (1999) Bła̧d medyczny [Medical Error] Krakowskie Wydawnictwo Medyczne. Kraków, Poland
10. Moffat AC, Osselton MD, Widdop B (eds) (2004) Clarke's analysis of drugs and poisons in pharmaceuticals, body fluids and postmortem material Pharmaceutical Press 2:1700
11. Mutschler E, Geisslinger G, Kroemer HK, Schafer-Korting M (2004) Mutschler Arzneimittelwirkungen. In: Danysz-Mutschler Farmakologia i toksykologia A (eds) Polish Edition. Medyczne Urban & Partner, Wrocław, Poland
12. Nelson RL (1982) The comparative clinical pharmacology and pharmacokinetics of vindesine, vincristine and vinblastine in human patients with cancer. Med Pediatr Oncol 10:115-127
13. O'Marcaigh AS, Bechter DL (1995) The vinca alkaloids. J Pediatr Oncol Nurs 12/3:140-142
14. Pharmidex Kompendium Leków, MediMedia International Sp.z o.o. (2002) Warszawa, Poland
15. Podlewski JK, Chwalibogowska-Podlewska A (1999) Leki Współ czesnej Terapii (Drugs of Contemporary Therapy). Fundacja Buchnera, Warszawa, Poland
16. Ramirez J, Ogan K, Ratain MJ (1997) Determination of vinca alkaloids In human plasma by liquid chromatography/atmospheric pressure chemical ionization mass spectrometry. Cancer Chemother Pharmacol 39:286-290
17. Thomas LL, Braat PC, Somers R, Goudsmit R (1982) Massive vincristine overdose:failure of leucovorin to reduce toxicity. Cancer Treat Rep 66/11:1967-1969
18. Watanabe K, West WL (1982) Calmodulin, activated cyclic nucleotide phosphodiesterase, microtubules, and the vinca alkaloids. Fed Proc 41:2229-2299
19. Weinberg JK (2002) Medical error and patient safety: understanding cultures in conflict; Law & Policy. Blackwell Publishers Ltd. 24(2)
20. http://www.enzypharm.com/en/wat_is_vasolastine.html