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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
involved schedule and time errors
involved wrong drugs
involved chemotherapy given to the wrong patient
were infused too slowly
were infused too fast
were correctlv administered at the prescribed rate
|Hospital stays||62.248 €|
|Additional drugs||23.658 €|
|Total annual cost||92.248 €|
Standard concentrations pre-prepared by pharmacy or industry , , ,
Standard concentrations pre-prepared by pharmacy or industry
Label/Color Code Concept 23, 24 and a Barcode/Data Matrix to handle preparation data and close the loop to patient 25
IV pumps with intuitive handling and integrated drug database 26,27,28 additionally, compatibility databases 29
Comprehensive and interprofessional education and training of all involved staff 28,29,30,31as well as ward-based clinical pharmacists30,32
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
 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.
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 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.
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 Noble D. (2010): The quest to eliminate intrathecal vinchristine errors: a 40-year journey. BMJ Quality & Safety 2010, 19, 323-326.
 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
 Arzneimittelkommission der deutschen Ärzteschaft (2005): Vincristin: Toedliche Zwischenfaelle nach versehentlicher intrathekaler Gabe. Deutsches Aerzteblatt 2005, 102,1615.
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 Kress R. et al. (2016): Unintentional Infusion of Phenylephrine into the Epidural Space. A&A Case Rep. 2016, 6(5),124-7.
 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
 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
 Ranchon et al. (2011): Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs. BMC Cancer 2011, 11:478.
 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.
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 Taxis K, Barber N,(2003) Etnographic study of incidence and serverity of intravenoius drug errors. BMJ 326:684
 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.
 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
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 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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