Conflict of interest: Nothing to declare.
Chemotherapy medication errors in a pediatric cancer treatment center: Prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate
Article first published online: 20 MAR 2013
Copyright © 2013 Wiley Periodicals, Inc.
Pediatric Blood & Cancer
Volume 60, Issue 8, pages 1320–1324, August 2013
How to Cite
Watts, R. G. and Parsons, K. (2013), Chemotherapy medication errors in a pediatric cancer treatment center: Prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate. Pediatr. Blood Cancer, 60: 1320–1324. doi: 10.1002/pbc.24514
Presented at the 25th Annual Meeting of the American Society of Pediatric Hematology–Oncology, May 11, 2012, New Orleans, Louisiana.
- Issue published online: 13 JUN 2013
- Article first published online: 20 MAR 2013
- Manuscript Accepted: 5 FEB 2013
- Manuscript Received: 4 JAN 2013
- dosing errors;
- medical errors;
- quality improvement
Chemotherapy medication errors occur in all cancer treatment programs. Such errors have potential severe consequences: either enhanced toxicity or impaired disease control. Understanding and limiting chemotherapy errors are imperative.
A multi-disciplinary team developed and implemented a prospective pharmacy surveillance system of chemotherapy prescribing and administration errors from 2008 to 2011 at a Children's Oncology Group-affiliated, pediatric cancer treatment program. Every chemotherapy order was prospectively reviewed for errors at the time of order submission. All chemotherapy errors were graded using standard error severity codes. Error rates were calculated by number of patient encounters and chemotherapy doses dispensed. Process improvement was utilized to develop techniques to minimize errors with a goal of zero errors reaching the patient.
Over the duration of the study, more than 20,000 chemotherapy orders were reviewed. Error rates were low (6/1,000 patient encounters and 3.9/1,000 medications dispensed) at the start of the project and reduced by 50% to 3/1,000 patient encounters and 1.8/1,000 medications dispensed during the initiative. Error types included chemotherapy dosing or prescribing errors (42% of errors), treatment roadmap errors (26%), supportive care errors (15%), timing errors (12%), and pharmacy dispensing errors (4%). Ninety-two percent of errors were intercepted before reaching the patient. No error caused identified patient harm. Efforts to lower rates were successful but have not succeeded in preventing all errors.
Chemotherapy medication errors are possibly unavoidable, but can be minimized by thoughtful, multispecialty review of current policies and procedures. Pediatr Blood Cancer 2013;601320-1324. © 2013 Wiley Periodicals, Inc.