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A cancer patient was scheduled to receive 3 mg of vinblastine daily for 5 days but instead received a seven-fold overdose of vinblastine, resulting in death. How could this happen?
To have syringes of vinblastine for Autosyringe available when the patient was ready to pick them up, a nurse working with the patient's doctor would call the outpatient oncology nurse with the order. The outpatient nurse would record the order on the patient's clinic chart and phone the satellite pharmacist to have him prepare the order she just transcribed. The pharmacist would prepare the doses and have them ready in a "will call" area. When the patient arrived with the actual prescription, the pharmacist would check it against what was made and then dispense the drug.
The outpatient nurse phoned the pharmacist for five vinblastine 20 mg syringes. She said one was to be infused I.V. daily for 5 days. The pharmacist prepared the syringes and placed them in the "will call" area. When the patient arrived, the outpatient nurse took the medication from the "will call" area and gave it to the patient without giving the prescription to the pharmacist. The prescription was actually written for 3 mg daily for 5 days. The nurse never checked nor did the pharmacist. After 3 days of therapy the patient became ill and the error was discovered. The patient eventually died.
The error occurred either with the office nurse's verbal transmission or with the outpatient nurse's call to the pharmacist. It was never determined for sure.
Drugs with as much potential for toxicity as anticancer drugs should never be dispensed secondary to a verbal order. If necessary, the order transmission process can be hastened with the use of fax machines. Written orders must be interpreted by both nurses and pharmacists.