A prescription and administration error of cisplatin: a case report

Automated prescribing has been reported to reduce medication errors from 80% to 50%. However, we report a medication error involving both physicians and pharmacists, as a result of the characteristics of the specific prescription software. Thus, a patient treated for an oesophagus carcinoma was administered 760 mg cisplatin instead of 190 mg intravenously. Consequences for the patient included pancytopenia and renal failure requiring hemodialysis. The medication error was identified as wrong prescription copying by a junior prescriber and the prescription was validated by mistake by the pharmacist in charge of dispensing.