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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  

      Nurse prepares infusion for chemotherapy patient

      “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

      Nurse scans a ribbon on the wrist of a chemotherapy patient

      More products that can help preventing medication errors 

      Did you know?

      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 port

      Ports and Needles

      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

      Product Measure

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

      Product Measure

      Product Measure

      Standard concentrations pre-prepared by pharmacy or industry

      Product Measure

      Product Measure

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

      Product Measure

      Product Measure

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

      Organizational Measures

      Organizational Measures

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

      Organizational Measures

      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

      Clara Pujol - hospital nurse

      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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      • HOW TO AVOID MEDICATION ERRORS IN CHEMOTHERAPY - CHECKLIST FOR PHYSICANS

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      Scientific Evidence

      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 

      3. Ford et al (2006): Study of Medication Errors on a Community Hospital Oncology Ward. Journal of Oncology Practice, 2006, 2 (4), 149-154. available at: https://ascopubs.org/doi/full/10.1200/jop.2006.2.4.149; accessed 02-23-2023. 

      4. ABC. (2015): South Australian Government launches inquiry over chemotherapy drug-dosing bungle. [online] available at: http://www.abc.net.au/news/2015-08-05/sa-government-launches-inquiry-over-chemotherapy- ungle/6673890; accessed 02-23-2023. 

      5. Lustig A. (2000): Medication error prevention by pharmacists – an Israeli solution. Pharmacy World and Science. 2000, 22 (1), 21–25. 

      6. Schulmeister L. (1999): Chemotherapy medication errors: descriptions, severity, and contributing factors. Oncol Nurs Forum. 1999; 26(6):1033-42. 

      7. MacIennan, L. (2016): Chemotherapy bungle at Adelaide hospitals due to clinical failures, SA Health Minister says. [online] available at: http://www.abc.net.au/news/2016-02-09/chemotherapy-bungle-at-adelaide-hospitals-under-review/7153168 accessed: 02-23-2023 

      8. Rooker JC, Gorard DA (2007): Errors of intravenous fluid infusion rates in medical inpatients. Clin Med. 2007;7: 482–5. available at: https://pdfs.semanticscholar.org/ec0d/acd06790eef073fb64a0678b74ca065e0516.pdf; accessed: 02-23-2023. 

      9. Hennipmann B. et al (2009): Intrathecal Vincristine. 3 Fatal Cases and a Review of the Literature. Journal Pediatric Hematol Oncol. 2009, 31 (11), 816-819. 

      10. Schulmeister L. (2006): Look-alike, sound-alike oncology medications. Clin J Oncol Nurs 2006, 10(1):35-41. 

      11. Bates DW et al (1995): Relationship between medication errors and adverse drug events. J Gen Intern Med 1995;10 (4):199-205 

      12. Noble D. (2010): The quest to eliminate intrathecal vinchristine errors: a 40-year journey. BMJ Quality & Safety 2010, 19, 323-326. 

      13. Toft B (2001): External Inquiry into the adverse incident that occurred at Queen’s Medical Centre, Nottingham, 4th January 2001, [online]. Available at: https://webarchive.nationalarchives.gov.uk/ukgwa/20080728185547/http://www.dh.gov.uk/en/Publications accessed: 02-23-2023 

      14. Arzneimittelkommission der deutschen Ärzteschaft (2005): Vincristin: Toedliche Zwischenfaelle nach versehentlicher intrathekaler Gabe. Deutsches Aerzteblatt 2005, 102,1615. 

      15. Dyer c (2001): Doctors suspended after injecting wrong drug into spine. BMJ 2001, 322 (7281). 257. 

      16. Kress R. et al. (2016): Unintentional Infusion of Phenylephrine into the Epidural Space. A&A Case Rep. 2016, 6(5),124-7. 

      17. International Organization for Standardization (2016): Small bore connectors for liquids and gases in healthcare applications -- Part 6: Connectors for neuraxial applications. [online] available at: https://www.iso.org/standard/50734.html accessed: 02-23-2023 

      18. Institute for Safe Medication Practices (2014): ISMP List of High-Alert Medications in Acute Care Settings [online] available at: https://www.ismp.org/sites/default/files/attachments/2018-01/highalertmedications%281%29.pdf accessed 06-07-2019 

      19. Ranchon et al. (2011): Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs. BMC Cancer 2011, 11:478. 

      20. Sasse M. et al. (2015): In-line Filtration Decreases Systemic Inflammatory Response Syndrome, Renal and Hematologic Dysfunction in Pediatric Cardiac Intensive Care Patients. Pediatric Cardiology 2015, 36 (6),1270–1278. 

      21. Reason, James (2000-). Human error: models and management. BMJ, 320 (7237): 768–770. 

      22. Weingart SN (2018): Chemotherapy medication errors. Lancet Oncol 2018, 19 (4), 191–99. 

      23. Parshuram CS, To T, Seto W, Trope A, Koren G, Laupacis A (2008) Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ; 178(1): 42-8. 

      24. Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T (2005) Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care; 14(3): 190-5. 

      25. Taxis K, Barber N,(2003) Etnographic study of incidence and serverity of intravenoius drug errors. BMJ 326:684 

      26. Dehmel C, Braune S, Keymann G, Baehr M, Langebrake C, Hilgarth H, Nierhaus A, Dartsch D, Kluge S (2011) Do centrallly pre-pared solutions achieve more reliable drug concentrations than solutions prepared on the ward? Intensive Care Med 2010-00231. R3 in press. 

      27. Tissot E. Cornette C, Limat S, Maourand J, Becker M, Etievent J et al. (2003) Observational study of potential risk factors of medication administration errors. J Qual Improve 25(6):264-68 

      28. Vogel Kahmann I, Bürki R et al. (2003) Incompatibility reactions in the intensive care unit. Five years after implementation of a simple "color code system". Anasthesist 52(5):409-12 

      29. Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P et al. (2009). Errors in adminstration of parental drugs in intensive care units: multinational prospective study. BMJ 338:b814. doi:10.1136/bmj.b814 

      30. Langebrake C, Hilgarth H (2010) Clinical pharmacists' interventions in a German University Hospital. Pharm World Svi 32(2):194-99 

      31. Taxis K (2005) Who is responsible for the safety of infusion devices? It's high time for action! QSHC 14(2):76 

      32. Rothschild JM, Keohane CA, Thompson S, Bates DW (2003) Intelligent Intravenous Infusion Pumps to improve Medication Administration Safety. AMIA Symposium Proceedings, p.992 

      33. Trissel LA (2011). Handbook on Injectable Drugs. 16th ed. Bethesda: American Society of Pharmacist. 

      34. Brigss J (2005) Strategies to reduce medication errors with reference to older adults. Best practice 9(4):1-6 

      35. Irajpour A, Farzi S, Saghaei M, Ravaghi H. Effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units. J Educ Health Promot. 2019 Oct 24;8:196. 

      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. 

      39. Smeulers M, Verweij L, Maaskant JM, de Boer M, Krediet CT, Nieveen van Dijkum EJ, Vermeulen H. (2015) Quality indicators for safe medication preparation and administration: a systematic review. PLoS One. 2015 Apr 17;10(4):e0122695. doi: 10.1371 

      40. Jones JH, Treiber L (2010) When 5 rights Go Wrong. J Nurs Care Qual 25:240-247 

      41. Schulmeister L (2007): Patient Misidentification in Oncology. Clinical Journal of Oncology Nursing 2007, 12 (3), 495-498. Available at: https://cjon.ons.org/cjon/12/3/patient-misidentification-oncology-care accessed: 02-23-2023 

      42. Schulmeister L (2002): Searching for Information for Presentations and Publications. Clinical Nurse Specialist, 2002, 16 (2); 79-84 

      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