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
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
- 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.