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Cancer Chemother Pharmacol (2007) 59:8995
DOI 10.1007/s00280-006-0246-1
ORIGINAL ARTICLE
Fatality involving vinblastine overdose as a result of a complex medical error
Magorzata Kys Tomasz Konopka Mariuszcisowski Piotr Kowalski
Received: 23 January 2006 / Accepted: 3 April 2006 / Published online: 8 July 2006 Springer-Verlag 2006
Abstract The purpose of the study is a presentation of a fatal case involving an 83-year-old woman, who died due to an overdose of vinblastinea cytostatic agent of a vinca alkaloid employed in cancer chemo-therapy. The postmortem investigation included an autopsy and histological examination, as well as a toxicological analysis of post-mortem specimens collected in the course of autopsy. The authors performed a toxicological assessment of vinblastine employing liquid chromatography-atmospheric pressure chemical ionization-tandem mass spectrometry (LC-MS-MSAPCI). The determined vinblastine concentration levels amounting to 29 ng/g in blood and 52.5 ng/g in liver were in a considerable excess of values encountered in patients on chemotherapy using the drug. The fatality was investigated in the context of medical error. In the described case, the erroneous and medically unjustied administration of vinblastine was identied by a series of unfortunate events involving as many as three acting consecutively individuals: a physician, a pharmacist and a nurse. The report may thus document the clinical course of vinblastine poisoning along with postmortem changes resulting from the drug action.
Keywords Vinblastine Overdosage Medical error Liquid chromatography Atmospheric pressure chemical ionization mass spectrometry
Introduction
Between the end of the 19th century and the present time, problems pertaining to medical errors have been discussed by eminent European medical and legal bodies. Numerous legal treatises of a fundamental character have concentrated on this issue, while dening conditions necessary for appropriate interventions. The problem of a medical error is, thus, ever-present in the history of medicine and it seems that despite the increasingly growing level of medical knowledge and various procedures aiming atat leastlimiting erroneous activities, the issue of medical errors continues to be live [9, 19].
In this context, an opportunity for discussing the issue of medical error is offered by the present report, which provides an analysis of a fatality in consequence of vinblastine (Vinblastin, Richter-Gedeon, H) over-dosagea cytostatic agent of a vinca alkaloid employed in cancer chemotherapy [14, 15].
In the described case, the erroneous and medically unjustied...