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Oncology

Medication errors in chemotherapy

Medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under the control of the health care professional, patient, or consumer.1 Medication errors can be classified by considering the types of errors occurring, such as wrong patient, dose, infusion rate, delivery route or medication. Medication errors may occur during any phase of the drug delivery process from prescription to drug administration and at anywhere medications are administered.2 Errors may occur with any medication; however, chemotherapy presents unique dangers due to narrow therapeutic indices, potential toxicity even at therapeutic dosages, complex regimens, and a vulnerable cancer patient population.3  

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“It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives and meet the challenges ahead.”

Linda T. Kohn et al, Committee on Quality of Health Care in America, Institute of Medicine
  • 0%

    involved over- and underdosing

  • 0%

    involved schedule and time errors

  • 0%

    involved wrong drugs

  • 0%

    involved chemotherapy given to the wrong patient

More products that can help minimise medication errors 

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Of a total of 207 Infusion Bags: 8, 13

  • 0%

    were infused too slowly

  • 0%

    were infused too fast

  • 0%

    were correctlv administered at the prescribed rate

26% were correctly administered at the prescribed rate

Risk: Wrong delivery route for chemotherapy delivery 

Most of the chemotherapy regimes are given intravenously, i.e. directly into the venous system. Peripheral venous access may be suitable, however, given the high toxicity of the drugs, mostly central venous access are preferred.

Vascular Access

A vascular access port device consists of a catheter connected to a reservoir. It is implanted subcutaneously and namely used to deliver drugs into the blood stream.

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Intercepeted errors, that have not been discovered, lead to 216 additional days of hospitalization.20

Hospital stays62.248 €
Additional drugs23.658 €
Total annual cost92.248 €

“Primum nil nocere. ”

– Hippokrates

Product Measure

Standard concentrations pre-prepared by pharmacy or industry  , , ,  

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Product Measure

Standard concentrations pre-prepared by pharmacy or industry

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Product Measure

Label/Color Code Concept 23, 24  and a Barcode/Data Matrix to handle preparation data and close the loop to patient 25

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Product Measure

 IV pumps with intuitive handling and integrated drug database 26,27,28  additionally, compatibility databases 29

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Organizational Measures

Comprehensive and interprofessional education and training of all involved staff 28,29,30,31as well as ward-based clinical pharmacists30,32

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Organizational Measures

Different storage areas for important drugs (e.g. concentrated potassium chloride) 33, 38 and introduction of separate medication preparation rooms on ward 34

Incident reporting system 30, 35, 36

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Risk: Wrong administration technique

Wrong administration techniques may comprise multiple aspects of the infusion. One example is discussed in the following: 

„Paclitaxel is a chemotherapeutic drug frequently used for breast, ovarial and bronchial cancer. The drug is likely to form microbubbles and particulate matter. The suppliers recommend that an in-line IV filter should be used during the infusion of the agent (SmpC Paclitaxel). Not using the inline filter might result in particles being infused into the patient 37.“

 

Particles arising from infusion therapy may induce or aggravate inflammatory response syndromes. They have been shown to generate thrombosis, impair microcirculation, and modulate immune response. Sources of particles include components of infusion systems, incomplete reconstitution of solutions or drug incompatibility reactions. Up to one million particles may be infused per patient per day. In-line filters incorporated into infusion lines retain particles and thereby nearly entirely prevent their infusion.41

Others would be errors in assembling giving sets for secondary infusions with or without pumps, Luer access-devices unintentionally left open after use or needlestick injury due to needle-based manipulation. 

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[1] National Coordinating Council for Medical Error Reporting and Prevention (NCCMERP): What is a Medication Error. available at: https://www.nccmerp.org/about-medication-errors; accessed 02-23-2023. 

[2] The Boston Globe, 2004 

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[36] Kane-Gill SL, Jacobi J, Rothschild JM (2010)  Adverse drug events in intensive care units: Risk factors, impact and the role of team care. Crit Care Med 38(6): 83-89 

[37] Etchells E, Juurllink D, Levinson W (2008) Medication Errors: the human factor. CMAJ 178(1):63 

[38] Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. Separate Medication Preparation Rooms Reduce Interruptions and Medication Errors in the Hospital Setting: A Prospective Observational Study. J Patient Saf. 2021 Apr 1;17(3):e161-e168. 

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[43] Goldspiel B, Hoffman JM, Griffith NL, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J HealthSyst Pharm. 2015; 72:e6–35