Fatal cisplatin overdose in the treatment of mediastinal lymphoma with the ESHAP regimen - analysis of the causes of the adverse drug event

• Published in: Onkologie Vol. 36; no. 1-2; p. 49
• Main Authors: Jurek, Tomasz, Rorat, Marta, Dys, Piotr, Swiatek, Barbara
• Format: Journal Article
• Language: English
• Published: Switzerland 2013
• Subjects: Adult; Antineoplastic Combined Chemotherapy Protocols - administration & dosage; Antineoplastic Combined Chemotherapy Protocols - poisoning; Cisplatin - administration & dosage; Cisplatin - poisoning; Cytarabine - administration & dosage; Cytarabine - poisoning; Drug Overdose - etiology; Etoposide - administration & dosage; Etoposide - poisoning; Fatal Outcome; Female; Humans; Lymphoma - complications; Lymphoma - drug therapy; Mediastinal Neoplasms - complications; Mediastinal Neoplasms - drug therapy; Medication Errors - adverse effects; Methylprednisolone - administration & dosage; Methylprednisolone - poisoning
• ISSN: 1423-0240
• DOI: 10.1159/000346677

Cisplatin is a chemotherapeutic agent that may cause acute (or chronic) organ toxicity. As there is no antidote, prevention of adverse drug events is essential for patients' safety. The authors present the case of a 33-year-old woman treated for lymphoma with the ESHAP regimen, who died of an overdose of cisplatin. The drug was administered at a rate 4 times greater than the recommended maximum dose. The first symptom of overdose - partial hearing loss - appeared after administration of the last dose of the drug on day 4 of the chemotherapy course. The initiation of intensive treatment with plasmapheresis and dialyses was ineffective. The patient died 18 days after receiving the last dose of cisplatin. The medication schedule had been prepared by an inexperienced physician. The information on cisplatin dosage had been sourced from a vague instruction in a clinical oncology manual: '100 mg/m(2) continuous i.v. infusion d.1-4'. The instruction was misinterpreted. The patient was given 100 mg/m(2) on each of the 4 days of the treatment. Special care must be taken when preparing a medication schedule; the treatment must be checked by an experienced physician and verified by the nursing staff. The patient should be monitored for symptoms of cisplatin intoxication.