IMPORTANT ERROR PREVENTION ADVISORY - CISPLATIN OVERDOSE

From the November 19, 1997 MSA Acute Care Edition Newsletter

According to news accounts this morning, a ten-month-old child died in a New Jersey teaching hospital this month after receiving 204 mg of Platinol® (cisplatin) instead of 20.4 mg. Press accounts state that the prescribing physician left out the decimal point. Nursing and pharmacy staff did not recognize the overdose.

Unfortunately, cisplatin overdoses are not a new problem. Recently, in response to past incidents, the drug's manufacturer, Bristol-Myers Squibb Oncology, worked with ISMP and an expert panel to revise package labeling. New warnings were added, including a statement that "Cisplatin doses greater than 100 mg/m2 once every 3 to 4 weeks are rarely used." At this time, it is not clear why the new packaging was not effective in this case.

The present case indicates the critical need for all practice sites that handle cisplatin to assure that the following safety systems are in place:

• Consider a policy of rounding all antineoplastic drug doses over 10 mg to the nearest whole number. This is especially important in pediatric patients. The 0.4 mg amount is this case was inconsequential. Had 20 mg been written, the accident would have been avoided. Hopefully, this incident can be used as an impetus to explore other drugs and situations where dose rounding would be beneficial as a step toward standardization and error prevention.
• Both the calculated daily dose and the mg/kg or mg/m2 basis for the dose should be required for pediatric patients and all cancer chemotherapy patients. This allows dose checking and facilitates recognition of incorrectly prescribed doses. Standard order forms should be used for cancer chemotherapy to "force" entry of this required information, body surface area (age and weight in children) and other critical clinical information.
• Computer screening of drug orders is essential to capture any excessive dose amounts that may be accidentally overlooked by practitioners. Many computer systems have this feature, but the necessary dose parameters have not always been entered into the system. If this feature is not available in your system, it should be. Stand alone systems with this feature are available (Berard et al. Computer software for pharmacy oncology services. Am J Health-Syst Pharm 1996;53:752-6).
• Inexperienced physicians, nurses, and pharmacists should have their work countersigned by knowledegable individuals (e.g., if house staff writes order, it should be countersigned by attending physician).
• There should be at least annual inservice education sessions about medication errors for all clinical staff.