Mar 12 • 10:59 UTC 🇯🇵 Japan Asahi Shimbun (JP)

Why are the instructions and different drugs used? The dispensing procedure at Saitama Children's Medical Center

Three patients treated for leukemia had their conditions worsen after being injected with a drug not intended for their treatment.

The Saitama Children's Medical Center disclosed on the 11th that three patients who received injections as part of their leukemia treatment experienced deteriorating health conditions. One patient has died, and two others are in critical condition after unidentified liquid was found in their cerebrospinal fluid—substances that should not have been present according to medical guidelines. As the situation raises serious questions regarding drug management and procedural integrity, the center is scrutinizing how such a critical error occurred.

At a press conference held on the same day, a center representative addressed concerns regarding possible human errors in the medication process. The official asserted that mistakes in instructions are not a common occurrence, implying that systematic factors may have contributed to the anomaly. All three patients underwent intrathecal injections, where medications are introduced directly into the spinal canal. However, a drug called vincristine, indicated for leukemia treatment, was discovered in their cerebrospinal fluid—an alarming finding as it is strictly administered intravenously and contraindicated for intrathecal use.

The center has launched an internal review to retrace the dispensing procedures and identify where the protocols might have faltered. The case has drawn widespread attention, emphasizing the urgent need for stringent oversight in medical practices, particularly in pediatric healthcare settings. The potential implications of this incident extend beyond immediate patient safety, as it may prompt calls for comprehensive reviews of procedural standards within medical institutions across the country.

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