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. At this time, it is not clear why the new packaging was not effective in this case. This is especially important in pediatric patients.