Riassunto
Alle 17.00 circa di giovedì 4 gennaio 2001 David James, un paziente in day-hospital nel reparto E17 del Queen’s Medical Centre Nottingham (QMC), venne preparato per la somministrazione intratecale (spinale) di chemioterapico, come previsto dal programma medico di mantenimento dopo il positivo trattamento di una forma di leucemia. Dopo aver eseguito la puntura lombare e aver somministrato la corretta terapia citotossica (citosina), sotto la supervisione del medico specialista dottor Mitchell, lo specializzando dottor North ricevette dal dottor Mitchell un secondo farmaco da somministrare al paziente, che in seguito morì. Purtroppo il secondo farmaco, la vincristina, non dovrebbe mai essere somministrato per via intratecale, perché è quasi sempre fatale. Sfortunatamente, nonostante la rapidità con cui venne effettuato il trattamento d’emergenza nel tentativo di riparare all’errore, alle ore 8.10 del 2 febbraio 2001 il paziente morì. (Toft, 2001)
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(2011). Capire come mai le cose vanno male. In: Tartaglia, R., Albolino, S., Bellandi, T. (eds) La sicurezza del paziente. Springer, Milano. https://doi.org/10.1007/978-88-470-1875-4_8
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