Literature DB >> 19306070

Erroneous administration of vinblastine.

Maciej Barzdo1, Leszek Zydek, Anna Smedra-Kaźmirska, Marian Zgoda, Waldemar Machała, Jarosław Berent.   

Abstract

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.

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Year:  2009        PMID: 19306070     DOI: 10.1007/s11096-009-9291-2

Source DB:  PubMed          Journal:  Pharm World Sci        ISSN: 0928-1231


  4 in total

1.  Effect of orthographic and phonological similarity on false recognition of drug names.

Authors:  B L Lambert; K Y Chang; S J Lin
Journal:  Soc Sci Med       Date:  2001-06       Impact factor: 4.634

2.  Similarity as a risk factor in drug-name confusion errors: the look-alike (orthographic) and sound-alike (phonetic) model.

Authors:  B L Lambert; S J Lin; K Y Chang; S K Gandhi
Journal:  Med Care       Date:  1999-12       Impact factor: 2.983

Review 3.  Medication errors caused by confusion of drug names.

Authors:  James M Hoffman; Susan M Proulx
Journal:  Drug Saf       Date:  2003       Impact factor: 5.606

4.  Severe hemorrhagic syndrome due to similarity of drug names.

Authors:  L Chiche; G Thomas; S Canavese; S Branger; R Jean; J M Durand
Journal:  Eur J Intern Med       Date:  2007-09-14       Impact factor: 4.487

  4 in total

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