Study of medication errors on a community hospital oncology ward

Deviations From Best Practice: Findings From a Certified Patient Safety Organization Remote-Verification Observational Study of Intravenous Compounding of Chemotherapeutic and Ancillary Drugs

Background: Chemotherapeutic and immunomodulatory medications can pose a serious risk to patient and healthcare provider safety because of complex processes, cytotoxicity, and prevalent medication use. Objective: To evaluate chemotherapeutic and ancillary medication compounding in hospital pharmacies using a remote verification system, focusing on pharmaceutical deviations from best practice, compounding time, medication waste, and cost. Methods: This retrospective, blinded observational study used a remote intravenous (IV) workflow verification system to examine IV chemotherapeutic compounding errors in large hospital systems. A Patient Safety Organization securely obtained >5000 compounding records and photos from the IV workflow system. Blinded pharmacists evaluated IV chemotherapy preparations using picture slide viewers to assess any deviations from best practice. Time variables, medication waste, STAT vs non-STAT orders, and cost were also evaluated. Results: The most frequently reported deviations from best practice included medications exceeding the >10% additive volume guideline (35.9%) and inaccurate dose labels (28.3%). Time flow analyses demonstrated a substantial increase in total compounding time per vial for 1 vs 2 vials. Most medications in this analysis had an average waste ranging from 0-.36 vials. STAT orders, accounting for 38.4% of all orders, wasted more medication than non-STAT orders. Gemcitabine cost analyses showed an association for number of vials and compounding time with overall cost per dose. Conclusion: Substantial inconsistencies between workflow stations were observed-highlighting the lack of standardization across chemotherapeutics, volume of medication waste during preparation, and the need to establish improved quality controls to safeguard patient and health care provider safety.

Uncovering the Risks of Anticancer Therapy Through Incident Report Analysis Using a Newly Developed Medical Oncology Incident Taxonomy

BACKGROUND

Incident reporting systems were developed to identify possible and actual harm in healthcare facilities. They have the potential to capture important safety trends and to enable improvements that can mitigate the risk of future patient harm and suffering. We recently developed and validated a taxonomy specific for medical oncology designed to enhance the identification, tracking, and trending of incidents that may lead to patient harm. The current project was designed to test the ability of such a taxonomy to be applied across different organizations delivering medical oncology care and to identify specific risks that could result in future harm.

METHODS

We analyzed 309 randomly selected medical oncology-related incident reports from 3 different cancer centers that had been posted between January 2019 and December 2020. Each report was assigned up to 2 incident categories. We used a 2-step process to reconcile reviewer discrepancies. In a secondary analysis, each of the incidents was reviewed and recoded to identify events which may result in major or catastrophic harm.

RESULTS

Three hundred four incidents met criteria for inclusion. Three hundred incidents (98.7%) were successfully coded. Sixty-seven percent of incidents were encompassed by the following 4 of 21 categories: prescriber ordering (22%), nursing care (15%), pharmacy (14%), and relational/communication issues (15%). Of 297 evaluable incidents, 47% did not reach the patient, 44.7% reached the patient without harm, 7.7% caused minor injury, and 0.7% caused severe injury or death. Submission rates by physicians varied between the 3 sites accounting for 1.7%, 10.7%, and 16.1% of reports. Secondary analysis identified 9 distinct scenarios that may result in major or catastrophic patient harm.

CONCLUSIONS

A medical oncology-specific incident reporting taxonomy has the potential to increase our understanding of inherent risks and may lead to process improvements that improve patient safety.

Medication errors in an oncology inpatient setting in India-Audit by clinical pharmacists

BACKGROUND

Good clinical practices and strict vigilance are needed, especially for patients receiving chemotherapy. Regular audits using a specially developed tool need to be conducted in the oncology wards to identify lapses in the use of chemotherapy drugs.

METHODOLOGY

Observational study was conducted in the adult and paediatric oncology inpatient settings in an Indian tertiary care hospital for a period of 2.5 years. It was an audit of case files of chemotherapy patients for their drug prescriptions, medication reconciliation records and adverse drug reports. Data was presented as frequencies and percentages.

RESULTS

1.3% medication errors and 0.23% adverse drug reactions were reported during the study period. Majority were transcription (38%) and drug reconstitution errors (29%) and were either in the near-miss or no-harm category.

CONCLUSION

Medication errors were found in the oncology wards, but due to the vigilance of clinical pharmacists, none of the patients were harmed as a consequence of these errors.

Error Detection and Cost Savings With an Image-Based Workflow Management System Connected to a Computerized Prescription Order Entry Program for Antineoplastic Compounding

OBJECTIVE

The aim of the study was to analyze both the prevalence of errors with the implementation of an image-based workflow management system during the antineoplastic compounding process, and the estimated costs associated with the negative clinical outcome if the errors had not been intercepted.

METHODS

Three months after the implementation of Phocus Rx system at a hospital pharmacy department, the identification, classification (type, preparation stage, and cause), and potential severity degree (from negligible to catastrophic) of the errors intercepted were determined. The probability of an error causing an adverse event if it had reached the patient (from nil [0] to high [0.6]) and its consequences was estimated by a team of clinical pharmacists and physicians. Cost-effectiveness analysis from the hospital's perspective was performed.

RESULTS

Overall, 9872 antineoplastic medications were prepared using Phocus Rx. The total compounding error rate was 0.8% (n = 78, 56 [69.2%] were related to incorrect dose, 20 [28.2%] to incorrect drug preparation or conditioning technique, and 2 [2.6%] were wrong drugs). Approximately 70% of the detected errors were classified as undetectable via the previous verification practice, with 11.55% judged to be potentially severe (n = 9) and 51.3% moderate (n = 29). Likelihood of occurrence of an adverse event was medium (0.4) to high (0.6) for 37.2% of the errors. Estimated cost ratio and return on investment were €4.21 and 321%, respectively.

CONCLUSIONS

The implementation of Phocus Rx prevented antineoplastic preparation errors that would have reached the patient otherwise. In addition, acquisition of this technology was estimated to be cost-effective.

Prevalence of Medication Errors and the Associated Factors: A Prospective Observational Study Among Cancer Patients at Mbarara Regional Referral Hospital

BACKGROUND

Medication error is one of the most common medical errors in the practice of modern medicine. Among cancer patients receiving chemotherapy, medication errors can be potentially harmful given the narrow therapeutic index, complex dosing, and toxic nature of anti-cancer drugs.

OBJECTIVE

This study aimed to determine the incidence and factors associated with medication errors among cancer patients.

METHODS

The study was a prospective observational study carried out at the cancer unit of Mbarara Regional Referral Hospital, Southwestern Uganda. The study included 110 participants, both adults and children receiving chemotherapy. The study was carried out for a period of five months from January to May 2020. A checklist was used to collect patient, medication, and disease information to identify the prescription, transcription, dispensing, and administration errors.

RESULTS

Of the 110 participants, 52 (47.3%) experienced a total of 78 medication errors (MEs). Of these, 33 (42.31%) were prescription errors, 29 (37.18%) administration errors, 9 (11.54%) transcription errors, and 7 (8.97%) dispensing errors. In the adjusted logistic regression of factors associated with medication errors, urban residents (aOR, 4.59; 95% CI, 1.08, 19.53, p= 0.039) and educated participants (at secondary level) (aOR, 10.51; 95% CI, 1.43, 77.14, p= 0.021) had a significantly higher risk of experiencing medication errors. Participants treated with alkylating agents (aOR, 2.87; 95% CI, 1.07, 7.72, p= 0.036) had a greater risk of experiencing medication errors when compared to other classes of chemotherapy.

CONCLUSION

The incidence of medication errors among cancer patients was high in Mbarara Regional Referral Hospital. Prescription errors were the most common type of error followed by administration errors, and dispensing errors were the least common. Residence, education level, and alkylating agent chemotherapy were significantly associated with occurrence of medication errors.

Use of failure modes and effects analysis to mitigate potential risks prior to implementation of an intravenous compounding technology

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

The purpose of this study was to identify potential failure points in a new chemotherapy preparation technology and to implement changes that prevent or minimize the consequences of those failures before they occur using the failure modes and effects analysis (FMEA) approach.

Methods

An FMEA was conducted by a team of medication safety pharmacists, oncology pharmacists and technicians, leadership from informatics, investigational drug, and medication safety services, and representatives from the technology vendor. Failure modes were scored using both Risk Priority Number (RPN) and Risk Hazard Index (RHI) scores.

Results

The chemotherapy preparation workflow was defined in a 41-step process with 16 failure modes. The RPN and RHI scores were identical for each failure mode because all failure modes were considered detectable. Five failure modes, all attributable to user error, were deemed to pose the highest risk. Mitigation strategies and system changes were identified for 2 failure modes, with subsequent system modifications resulting in reduced risk.

Conclusion

The FMEA was a useful tool for risk mitigation and workflow optimization prior to implementation of an intravenous compounding technology. The process of conducting this study served as a collaborative and proactive approach to reducing the potential for medication errors upon adoption of new technology into the chemotherapy preparation process.

Robotic chemotherapy compounding: A multicenter productivity approach

INTRODUCTION

The aim of this study is to compare productivity of the KIRO Oncology compounding robot in three hospital pharmacy departments and identify the key factors to predict and optimize automatic compounding time.

METHODS

The study was conducted in three hospitals. Each hospital compounding workload and workflow were analyzed. Data from the robotic compounding cycles from August 2017 to July 2018 were retrospectively obtained. Nine cycle specific parameters and five productivity indicators were analysed in each site. One-to-one differences between hospitals were evaluated. Next, a correlation analysis between cycle specific factors and productivity indicators was conducted; the factors presenting a highest correlation to automatic compounding time were used to develop a multiple regression model (afterwards validated) to predict the automatic compounding time.

RESULTS

A total of 2795 cycles (16367 preparations) were analysed. Automatic compounding time showed a relevant positive correlation (ǀr_s|>0.40) with the number of preparations, number of vials and total volume per cycle. Therefore, these cycle specific parameters were chosen as independent variables for the mathematical model. Considering cycles lasting 40 minutes or less, predictability of the model was high for all three hospitals (R²:0.81; 0.79; 0.72).

CONCLUSION

Workflow differences have a remarkable incidence in the global productivity of the automated process. Total volume dosed for all preparations in a cycle is one of the variables with greater influence in automatic compounding time. Algorithms to predict automatic compounding time can be useful to help users in order to plan the cycles launched in KIRO Oncology.

Chemotherapy medication errors

Although chemotherapy is a well established treatment modality, chemotherapy errors represent a potentially serious risk of patient harm. We reviewed published research from 1980 to 2017 to understand the extent and nature of medication errors in cancer chemotherapy, and to identify effective interventions to help prevent mistakes. Chemotherapy errors occur at a rate of about one to four per 1000 orders, affect at least 1-3% of adult and paediatric oncology patients, and occur at all stages of the medication use process. Oral chemotherapy use is a particular area of growing risk. Our knowledge of chemotherapy errors is drawn primarily from single-institution studies at university hospitals and referral centres, with a particular focus on prescription orders and pharmacy practices. Although the heterogeneity of research methods and measures used in these studies limits our understanding of this issue, the rate of chemotherapy error-related injuries is generally lower than those seen in comparable studies of general medical patients. Although many interventions show promise in reducing chemotherapy errors, most have little empirical support. Additional research is needed to understand and to mitigate the risk of chemotherapy medication errors.

A virtual centralized cytotoxic preparation unit simulation to evaluate the pharmacy staff knowledge

BACKGROUND

The risk of medication errors related to drug preparation unit cannot be totally avoided because of human interference. The aim of this study is to investigate the background and knowledge of the pharmacy staff by replicating the cytotoxic preparation unit with potential errors.

METHODS

A 10-m² room was provided to duplicate the centralized chemotherapy unit with three areas reproducing virtually the equipment preparation bench, the isolator, and the dispensing bench. The 14 situations selected by experts were integrated to each corresponded area. For each participant, a form was given and answers were analyzed by two independent experts. Statistical processing data were performed using GraphPad Prism® software.

RESULTS

A total of 19 professionals participated in error simulation workshop over a one-month period. The overall rate of correct responses was 58 ± 19%. In five situations, correct responses rate was lower than 50%: wrong drug batch related to the preparation sheet (40%), inappropriate sterilizing conditions (15%), the time on the preparation sheet provides an expired expiry date for melphalan preparation (45%), a maximum drug dose exceeded (25%), the dispensing form not corresponds to the preparation sheet and final product label (30%). The rate of correct responses was 45 ± 25% for professionals not specifically dedicated to chemotherapy preparation. The overall satisfaction workshop rate was 8.7 ± 1.0 out of 10.

CONCLUSION

This study showed the importance of training programs to sensitize personal staff to the risks of chemotherapy preparation and prevent errors.

Exploring healthcare professionals' perceptions of medication errors in an adult oncology department in Saudi Arabia: A qualitative study

Objective

Adverse events which result from medication errors are considered to be one of the most frequently encountered patient safety issues in clinical settings. We undertook a qualitative investigation to identify and explore factors relating to medication error in an adult oncology department in Saudi Arabia from the perspective of healthcare professionals.

Methods

This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining required ethical approvals and written consents from the participants, semi-structured interviews and focus group discussions were carried out for data collection. A stratified purposive sampling strategy was used to recruit medical doctors, pharmacists, and nurses. NVivo Pro version 11 was used for data analyses. Inductive thematic analysis was adopted in the primary coding of data while secondary coding of data was carried out deductively applying the Hospital Survey of Patient Safety Culture (HSOPSC) framework.

Result

The total number of participants were 38. Majority of the participants were nurses (n = 24), females (n = 30), and not of Saudi nationality (n = 31) with an average age of 36 years old. Causes of medication errors were categorized into 6 themes. These causes were related teamwork across units, staffing, handover of medication related information, accepted behavioural norms, frequency of events reported, and non-punitive response to error.

Conclusion

There were numerous causes for medication errors in the adult oncology department. This means substantive improvement in medication safety is likely to require multiple, inter-relating, complex interventions. More research should be conducted to examine context-specific interventions that may have the potential to improve medication safety in this and similar departments.

A robotic system to prepare IV solutions

Drugs need to be used regularly and correctly in order to be effective. When medicines are used correctly, negativities that threaten human health and life can be avoided, but they can cause unwanted situations that can occur until the end of life when they are used incorrectly. The most common drug administration errors in hospitals are: The wrong dosage of the drug given to the patient, the timing and / or the method of administration, the wrong drug given to the patient, the drug given to the wrong patient, or even not given. Furthermore, the information about the drug that is administered to the patient may not be registered at all. In this research, a robotic drug preparation system and a communication server accepting prescription orders have been developed. Component engineering methodology is further utilized in the design of the Drug Preparation System to maximize reuse, increase product reliability, reduce design, code and test efforts. The IV Robotic Drug Preparation Robot is composed of a robotic work station and a Cartesian carrier to carry the work station to the desired location. The robotic work station has several grippers to handle syringes, to pull the piston of the syringe and to lock the closed system connector to the vial. The IV Robotic Drug Preparation System and communication server are developed and being used in the hospitals. Due to this system, medicines left unused in vials can be used and a great amount of savings is obtained from the drug purchases.

The Impact of an Automated Dispensing System for Supplying Narcotics in a Surgical Unit: The Experience of the National Cancer Institute Foundation of Milan

Objective: An automated dispensing system for narcotic drugs was introduced in a surgical unit to be compliant with the Italian narcotic drugs regulation. The aim of this study was to evaluate the impact of this automated dispensing system on the incidence of registry errors and corrections and on staff time and hospital costs. Methods: In 2014, Pyxis MedStation 3500 was introduced in a surgical unit of the National Cancer Institute of Milan, to improve the effectiveness of narcotics dispensing and avoid potential errors. Two different time periods of 8 months were compared, respectively, before and after the introduction of the automated dispensing system. In the pre-Pyxis period, drug movements were recorded through paper registries, while in the post-Pyxis period, electronic reports were automatically created from the system. For each period, the number of load/unload registry entries and corrections, the number of registry errors, the staff time dedicated to dispensing and registry activities, and stock and expired drug quantities were recorded. Results: Load and unload errors were reduced by 100% from the pre-Pyxis period to the post-Pyxis period, while registry corrections were lowered by 95%. Time dedicated from nurses to dispensing registration activities was reduced from 36 to 2 hours/month, while pharmacist time lowered from 9 to 1 hours/month. These time savings correspond to an economic saving of ~€4,120 and ~€3,730, respectively. In the post-Pyxis period, average operating room stock quantities were reduced versus the pre-Pyxis period, with wastage being 100% avoided. The reduction in stock drug quantities could correspond to an economic saving of ~€22,300 over the examined 8-month period, while the impact of drug wastage avoidance is modest (~€650). Conclusion: The overall economic impact of Pyxis use, over the 8-month time horizon in analysis, was around €31,000 saved or possibly converted into resource cost dedicated to other added value activities.

Lymphoma Therapy and Adverse Events: Nursing Strategies for Thinking Critically and Acting Decisively

BACKGROUND

Multiple treatment options, combined with disease heterogeneity, have created nursing challenges in the management of adverse events (AEs) during antilymphoma therapy. Testing has revealed that less than half of participating nurses correctly graded peripheral neuropathy and neutropenia related to antilymphoma regimens.

OBJECTIVES

This article identifies nursing challenges in the management of AEs associated with therapy for lymphomas and describes how strategies in critical thinking can help meet those challenges.

METHODS

A comprehensive literature search in oncology nursing, nursing education, and critical thinking was conducted; participant responses to pre- and post-tests at nursing education programs were evaluated; and a roundtable meeting of authors was convened.

FINDINGS

Oncology nurses can cultivate critical thinking skills, practice thinking critically in relation to team members and patients, leverage information from the Patient-Reported Outcomes Common Terminology Criteria for Adverse Events, and manage workflow to allow more opportunity for critical thinking.

Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences

BACKGROUND

Double-checking is widely recommended as an essential method to prevent medication errors. However, prior research has shown that the concept of double-checking is not clearly defined, and that little is known about actual practice in oncology, for example, what kind of checking procedures are applied.

OBJECTIVE

To study the practice of different double-checking procedures in chemotherapy administration and to explore nurses' experiences, for example, how often they actually find errors using a certain procedure. General evaluations regarding double-checking, for example, frequency of interruptions during and caused by a check, or what is regarded as its essential feature was assessed.

METHODS

In a cross-sectional survey, qualified nurses working in oncology departments of 3 hospitals were asked to rate 5 different scenarios of double-checking procedures regarding dimensions such as frequency of use in practice and appropriateness to prevent medication errors; they were also asked general questions about double-checking.

RESULTS

Overall, 274 nurses (70% response rate) participated in the survey. The procedure of jointly double-checking (read-read back) was most commonly used (69% of respondents) and rated as very appropriate to prevent medication errors. Jointly checking medication was seen as the essential characteristic of double-checking-more frequently than 'carrying out checks independently' (54% vs 24%). Most nurses (78%) found the frequency of double-checking in their department appropriate. Being interrupted in one's own current activity for supporting a double-check was reported to occur frequently. Regression analysis revealed a strong preference towards checks that are currently implemented at the responders' workplace.

CONCLUSIONS

Double-checking is well regarded by oncology nurses as a procedure to help prevent errors, with jointly checking being used most frequently. Our results show that the notion of independent checking needs to be transferred more actively into clinical practice. The high frequency of reported interruptions during and caused by double-checks is of concern.

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: A systematic review

BACKGROUND

Opioids are the primary pharmacological treatment for cancer pain and, in the palliative care setting, are routinely used to manage symptoms at the end of life. Opioids are one of the most frequently reported drug classes in medication errors causing patient harm. Despite their widespread use, little is known about the incidence and impact of opioid medication errors in oncology and palliative care settings.

AIM

To determine the incidence, types and impact of reported opioid medication errors in adult oncology and palliative care patient settings.

DESIGN

A systematic review.

DATA SOURCES

Five electronic databases and the grey literature were searched from 1980 to August 2014. Empirical studies published in English, reporting data on opioid medication error incidence, types or patient impact, within adult oncology and/or palliative care services, were included. Popay's narrative synthesis approach was used to analyse data.

RESULTS

Five empirical studies were included in this review. Opioid error incidence rate was difficult to ascertain as each study focussed on a single narrow area of error. The predominant error type related to deviation from opioid prescribing guidelines, such as incorrect dosing intervals. None of the included studies reported the degree of patient harm resulting from opioid errors.

CONCLUSION

This review has highlighted the paucity of the literature examining opioid error incidence, types and patient impact in adult oncology and palliative care settings. Defining, identifying and quantifying error reporting practices for these populations should be an essential component of future oncology and palliative care quality and safety initiatives.

Effect of unintentional cyclophosphamide underdosing on diffuse large B-cell lymphoma response to chemotherapy: a retrospective review

BACKGROUND

Between March 2012 and March 2013, a miscommunication in labelling between the drug compounder supplier and cancer centre pharmacies resulted in accidental overdilution of cyclophosphamide and gemcitabine used by several cancer centres in Canada. At our centre, 177 hematology patients were affected, among whom the largest subset of patients was those with diffuse large B-cell lymphoma. In this study, we evaluated the effect of such underdosing on disease response.

METHODS

We conducted a retrospective cohort study involving all patients with diffuse large B-cell lymphoma who received at least 1 chemotherapy cycle containing diluted cyclophosphamide at our centre and compared them with a historical group of patients matched by stage and age. The primary outcome was event-free survival (a composite of disease progression or death). Secondary outcomes included complete remission and overall response rate. Groups were compared using unpaired Student t, χ2 or Fisher exact tests, as appropriate. Survival analysis was done using the Kaplan-Meier method.

RESULTS

Event-free survival was no different between groups (log-rank p = 0.99). At a median follow-up of 548 days, progression or death occurred in 21 of 77 patients in the case group (27.3%) and in 24 of 74 patients in the control group (32.4%) (p = 0.5). At the end of treatment, complete remission was achieved in 41 patients in the case group (53.2%) and 43 patients in the control group (57.3%) (p = 0.6), whereas overall response rate was 71.4% in the case group and 66.7% in the control group (p = 0.5).

INTERPRETATION

Compared with a historical control group, we found no differences in event-free survival or response rates among patients with diffuse large B-cell lymphoma who received 1 or more doses of accidentally diluted cyclophosphamide-containing chemotherapy.

Nurses' role in medical error recovery: an integrative review

AIMS AND OBJECTIVES

The aim of this study was to conduct an integrative review of the literature to fully understand nurses' role in medical error recovery.

BACKGROUND

Despite focused efforts on error prevention, the prevalence of medical errors occurring in the health care system remains a concern. Patient harm can be reduced or prevented by adequate recovery processes that include identifying, interrupting and correcting medical errors in a timely fashion. Both medical error prevention and recovery are critical components in advancing patient safety, yet little is known about nurses' role in medical error recovery.

DESIGN

An integrative review of the literature, guided by Whittmore and Knafl's (Journal of Advanced Nursing, 5, 2005, 546) five-step process, was conducted for the period between 2000-2015. A comprehensive search yielded twelve articles for this review.

METHODS

The level and quality of evidence of the included articles was rated using a five-level rating system and the Johns Hopkins Nursing Quality of Evidence Appraisal developed by ©The Johns Hopkins Hospital/The Johns Hopkins University.

RESULTS

The medical error recovery rate varied across specialty nursing populations with nurses recovering, on average, as many as one error per shift to as few as one error per week. Nurses rely on knowing the patient, environment and plan of care to aid in medical error recovery.

CONCLUSIONS

Nurses play a unique yet invisible role in identifying, interrupting and recovering medical errors. Individual and organisational factors influencing nurses' ability to recover medical errors remain unclear.

RELEVANCE TO CLINICAL PRACTICE

Greater understanding of nurse characteristics and organisational factors that influence error recovery can foster the development of effective strategies to detect and correct medical errors and enable organisations to reduce negative outcomes.

Prescription errors in cancer chemotherapy: Omissions supersede potentially harmful errors

Objective:

To estimate the frequency and type of prescription errors in patients receiving cancer chemotherapy.

Settings and Design:

We conducted a cross-sectional study at the day care unit of the Regional Cancer Centre (RCC) of a tertiary care hospital in South India.

Materials and Methods:

All prescriptions written during July to September 2013 for patients attending the out-patient department of the RCC to be treated at the day care center were included in this study. The prescriptions were analyzed for omission of standard information, usage of brand names, abbreviations and legibility. The errors were further classified into potentially harmful ones and not harmful based on the likelihood of resulting in harm to the patient. Descriptive analysis was performed to estimate the frequency of prescription errors and expressed as total number of errors and percentage.

Results:

A total of 4253 prescribing errors were found in 1500 prescriptions (283.5%), of which 47.1% were due to omissions like name, age and diagnosis and 22.5% were due to usage of brand names. Abbreviations of pre-medications and anticancer drugs accounted for 29.2% of the errors. Potentially harmful errors that were likely to result in serious consequences to the patient were estimated to be 11.7%.

Conclusions:

Most of the errors intercepted in our study are due to a high patient load and inattention of the prescribers to omissions in prescription. Redesigning prescription forms and sensitizing prescribers to the importance of writing prescriptions without errors may help in reducing errors to a large extent.

Infusional chemotherapy and medication errors in a tertiary care pediatric cancer unit in a resource-limited setting

BACKGROUND

Drug administration is a multiprofessional process. The high toxicity and low therapeutic index of chemotherapy drugs make medication errors a significant problem, resulting in excessive patient morbidity and cost.

OBJECTIVE

An audit of the delivery of infusional chemotherapy among pediatric inpatients was planned, with the objective of improving practice and minimizing errors.

METHOD

An observational study was conducted between January and August 2012. Patients were followed up from their premedication until the completion of postchemotherapy hydration and/or rescue drugs. Errors were recorded and classified by error type, cause, severity, unit location, medication involved, and harm caused.

RESULTS

A total of 205 observations were made and 23(13.6%) errors recorded, of which 6 were intercepted. No life-threatening adverse drug event was recorded. The most important risk factor predisposing to errors was admission to nonpediatric ward (P=0.004). Documentation errors and incorrect infusion time were the 2 most common errors, whereas the most frequent error node was administration error. Appropriate steps were taken to prevent their reoccurrence.

CONCLUSIONS

This study helped provide important information about the rate and epidemiology of medication errors, emphasizing on the role of audit in enabling development of appropriate error-reducing strategies, particularly in the context of quality assurance in hospitals.

Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis

OBJECTIVE

To evaluate the impact of electronic standardized chemotherapy templates on incidence and types of prescribing errors.

DESIGN

A quasi-experimental interrupted time series with segmented regression.

SETTING

A 700-bed multidisciplinary tertiary care hospital with an ambulatory cancer center.

PARTICIPANTS

A multidisciplinary team including oncology physicians, nurses, pharmacists and information technologists.

INTERVENTION(S)

Standardized, regimen-specific, chemotherapy prescribing forms were developed and implemented over a 32-month period.

MAIN OUTCOME MEASURE(S)

Trend of monthly prevented prescribing errors per 1000 chemotherapy doses during the pre-implementation phase (30 months), immediate change in the error rate from pre-implementation to implementation and trend of errors during the implementation phase. Errors were analyzed according to their types: errors in communication or transcription, errors in dosing calculation and errors in regimen frequency or treatment duration. Relative risk (RR) of errors in the post-implementation phase (28 months) compared with the pre-implementation phase was computed with 95% confidence interval (CI).

RESULTS

Baseline monthly error rate was stable with 16.7 prevented errors per 1000 chemotherapy doses. A 30% reduction in prescribing errors was observed with initiating the intervention. With implementation, a negative change in the slope of prescribing errors was observed (coefficient = -0.338; 95% CI: -0.612 to -0.064). The estimated RR of transcription errors was 0.74; 95% CI (0.59-0.92). The estimated RR of dosing calculation errors was 0.06; 95% CI (0.03-0.10). The estimated RR of chemotherapy frequency/duration errors was 0.51; 95% CI (0.42-0.62).

CONCLUSIONS

Implementing standardized chemotherapy-prescribing templates significantly reduced all types of prescribing errors and improved chemotherapy safety.

Chemotherapy patients' perceptions of drug administration safety

PURPOSE

To explore chemotherapy patients' experiences of drug administration safety and to investigate the relationship between perceptions of risk and harm from error, staff safety practices, and patients' engagement in error prevention strategies.

PATIENTS AND METHODS

Four hundred seventy-nine chemotherapy patients treated at the oncology/hematology department of a large regional hospital in Switzerland completed a self-administered survey (53% response rate).

RESULTS

Sixteen percent of patients reported having experienced an error in their care, and 11% were currently very concerned about errors. Patients perceived the risk of four detailed errors as rather low, whereas the mean rating of potential harm from error was substantial. Relative to other errors, patients seem to underestimate the harm associated with drug overdosing. Seventy-seven percent of responders agreed that patients can help to prevent errors. Although patients perceived staff as being committed to providing safe care, ratings related to patient involvement in safety were considerably lower. More than one quarter of patients disagreed that staff instructed them to watch for and report errors. Patients engaged in safety behaviors, particularly in those behaviors that are compatible with traditional patient-provider relations. Risk of error perceptions, affirmative attitudes toward patient preventability, and error experience were positively linked to safety-related behaviors, whereas higher levels of global trust in staff safety practices were inconsistently associated with lower frequency of engagement in safety strategies.

CONCLUSION

Chemotherapy safety is a considerable concern for patients. Many patients are prepared to be involved in error prevention. The results highlight areas for improvement in communication and cooperation for safety between patients and providers.

American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards

Standardization of care can reduce the risk of errors, increase efficiency, and provide a framework for best practice. In 2008, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) invited a broad range of stakeholders to create a set of standards for the administration of chemotherapy to adult patients in the outpatient setting. At the close of a full-day structured workshop, 64 draft standards were proposed. After a formal process of electronic voting and conference calls, 29 draft standards were eliminated, resulting in a final list of 35 draft measures. The proposed set of standards was posted for 6 weeks of open public comment. Three hundred twenty-two comments were reviewed by the Steering Group and used as the basis for final editing to a final set of standards. The final list includes 31 standards encompassing seven domains, which include the following: review of clinical information and selection of a treatment regimen; treatment planning and informed consent; ordering of treatment; drug preparation; assessment of treatment compliance; administration and monitoring; assessment of response and toxicity monitoring. Adherence to ASCO and ONS standards for safe chemotherapy administration should be a goal of all providers of adult cancer care.

American Society Of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards

Standardization of care can reduce the risk of errors, increase efficiency, and provide a framework for best practice. In 2008, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) invited a broad range of stakeholders to create a set of standards for the administration of chemotherapy to adult patients in the outpatient setting. At the close of a full-day structured workshop, 64 draft standards were proposed. After a formal process of electronic voting and conference calls, 29 draft standards were eliminated, resulting in a final list of 35 draft measures. The proposed set of standards was posted for 6 weeks of open public comment. Three hundred twenty-two comments were reviewed by the Steering Group and used as the basis for final editing to a final set of standards. The final list includes 31 standards encompassing seven domains, which include the following: review of clinical information and selection of a treatment regimen; treatment planning and informed consent; ordering of treatment; drug preparation; assessment of treatment compliance; administration and monitoring; and assessment of response and toxicity monitoring. Adherence to ASCO and ONS standards for safe chemotherapy administration should be a goal of all providers of adult cancer care.

Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature

Medication errors in chemotherapy occur frequently and have a high potential to cause considerable harm. The objective of this article is to review the literature of medication errors in chemotherapy, their incidences and characteristics, and to report on the growing evidence on involvement of patients in error prevention. Among all medication errors and adverse drug events, administration errors are common. Current developments in oncology, namely, increased outpatient treatment at ambulatory infusion units and the diffusion of oral chemotherapy to the outpatient setting, are likely to increase hazards since the process of preparing and administering the drug is often delegated to patients or their caregivers. While professional activities to error incidence reduction are effective and important, it has been increasingly acknowledged that patients often observe errors in the administration of drugs and can thus be a valuable resource in error prevention. However, patients need appropriate information, motivation and encouragement to act as 'vigilant partners'. Examples of simple strategies to involve patients in their safety are presented. Evidence indicates that high self-efficacy and perceived effectiveness of the specific preventive actions increase likelihood of participation in error prevention. Clinicians play a crucial role in supporting and enabling the chemotherapy patient in approaching errors.

How accurate is information transmitted to medical professionals joining a medical emergency? A simulator study

OBJECTIVE

This study used a high-fidelity simulation to examine factors influencing the accuracy of 201 pieces of information transmitted to nurses and physicians joining a medical emergency situation.

BACKGROUND

Inaccurate or incomplete information transmission has been identified as a major problem in medicine. However, only a few studies have assessed possible causes of transmission errors.

METHOD

Each of 20 groups was composed of two or three nurses (first responders), one resident joining the group later, and one senior doctor joining last. Groups treated a patient suffering a cardiac arrest.

RESULTS

Multilevel binomial analyses showed that 18% of the information given to newcomers was inaccurate. Quantitative information requiring repeated updating was particularly error prone. Information generated earlier (i.e., older information) was more likely to be transmitted inaccurately. Explicitly encoding information to be transmitted after the physicians arrived at the scene enhanced accuracy, supporting transfer-appropriate processing theory.

CONCLUSION

Information transmitted to nurses and physicians who join an ongoing emergency is only partly reliable. Therefore, medical professionals should not take accuracy for granted and should be aware of the nature of transmission errors.

APPLICATION

Medical professionals should be trained in adequate encoding of information and in standardized communication procedures with regard to error-prone information. In addition, technical devices should be implemented that reduce reliance on memory regarding information with error-prone characteristics.