Erroneous administration of vinblastine.

Area of Science:

• Pharmacology
• Medical Errors
• Patient Safety

Background:

• An 83-year-old patient presented with unspecified complaints.
• The physician intended to prescribe Vasolastine, a medication for angiopathy.

Observation:

• The physician misspelled Vasolastine as 'Vinplastyna', a non-existent drug.
• A pharmacist dispensed Vinblastine, a chemotherapy agent, instead of the intended medication.
• Community nurses administered Vinblastine daily for seven days.

Findings:

• The patient developed myelophthisis (bone marrow failure) after the seventh dose.
• The patient was admitted to the Intensive Care Ward and subsequently died.

Implications:

• This case underscores the severe consequences of medication errors, including incorrect drug dispensing and administration.
• It highlights the need for robust systems to prevent prescription errors and ensure correct medication dispensing.
• Improved patient safety protocols are crucial to avoid such preventable deaths in clinical practice.