Errors involving cytotoxic drugs have the potential of being fatal and should therefore be prevented. The objective of this article is to identify the characteristics of medication errors involving parenteral cytotoxic drugs in Sweden. A total of 60 cases reported to the national error reporting systems from 1996 to 2008 were reviewed. Classification was made to identify cytotoxic drugs involved, type of error, where the error occurred, error detection mechanism, and consequences for the patient. The most commonly involved cytotoxic drugs were fluorouracil, carboplatin, cytarabine and doxorubicin. The platinum-containing drugs often caused serious consequences for the patients. The most common error type were too high doses (45%) followed by wrong drug (30%). Twenty-five of the medication errors (42%) occurred when doctors were prescribing. All of the preparations were delivered to the patient causing temporary or life-threatening harm. Another 25 of the medication errors (42%) started with preparation at the pharmacies. The remaining 10 medication errors (16%) were due to errors during preparation by nurses (5/60) and administration by nurses to the wrong patient (5/60). It is of utmost importance to minimise the potential for errors in the prescribing stage. The identification of drugs and patients should also be improved.

This study investigated the rationale of boron neutron capture therapy (BNCT) for the treatment of Grade III and IV astrocytoma. The European Community joint research program on BNCT plans to use sulfhydryl boron hydride (BSH) in clinical trials. The work presented here, examines the performance of BSH in eight patients with Grade III and IV astrocytoma using a measurement technique which precisely correlates the boron uptake with the histology of the tumor and the peritumoral brain. Astrocytomas are exceptionally heterogeneous and spread migrating tumor cells into the surrounding brain. The patients were infused with 50 mg BSH per kilogram of body weight at 12, 18, 24 or 48 hours before surgery. At the time of operation, specimens were obtained of the tumor, skin, muscle, dura, blood, urine, and, when surgically possible, the brain adjacent to tumor. In three patients the intracellular boron distribution was investigated by subcellular fractionation. The blood clearance was biphasic with half-lives of 0.6 and 8.2 hours. After 3 days, approximately 70% of the dose injected was excreted in the urine. The maximum boron concentration in the tumor was 20 ppm, 12 hours after the infusion. The tumor-to-blood ratios ranged between 0.2 and 1.4, with the highest values after 18 to 24 hours. In the brain specimens the boron concentration never exceeded 1 ppm. This work confirms a selective uptake of boron in the tumor compared to the surrounding brain and that boron, to some extent, is incorporated in the tumor cells.

A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs) in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason's Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips, one‐third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self‐evaluation tool that would work as a complement to already incident reporting and event and risk analyses.

BACKGROUND To reduce chemotherapy errors, accurate information about chemotherapy drugs and regimens is needed. A national e-library, as a common knowledge source with standardized chemotherapy nomenclature and content was developed. Since the information in the library is both complex and extensive it is central that the users can utilize the resource as intended. OBJECTIVE The aim of this study was to evaluate the usage and usability of an extensive e-library for chemotherapy regimens developed to reduce medication errors and increase patient safety. METHODS To obtain a comprehensive evaluation, a mixed method was applied for a broad view of the usage, including compilation of subjective views of the users (web survey, spontaneous user feedback, and qualitative interviews), analysis of statistics from the website, and an expert evaluation of the usability of the webpage. RESULTS Statistics from the website show an average of just over 2,500 visits and 870 unique visitors per month. Most visits took place Mondays to Fridays, but there were 5-10 visits per day on weekends. The web survey, with 292 answers, shows that the visitors were mainly physicians and nurses. Almost 80% searched for regimens, 90% found what they were looking for, and were satisfied with their visit. The expert evaluation show that the e-library follows many existing design principles giving some useful improvement suggestions. A total of 86 emails during 2020 giving user feedback were received, most of them from nurses. Main part (78%) contained a question and the rest had discovered incorrectness mainly in some regimen. The interviews reveal that most hospital use a computerized physician order entry system and they use the e-library in various ways, import XML files, transfer information or as a reference. One hospital without a system use the administration schedules from the library. CONCLUSIONS The user evaluation indicate that the e-library is used in the intended way and that the users can interact without problems. Users have different needs depending on their profession and their workplace and these can be supported. The combination of methods applied, ensures that the design and content comply with the users’ needs and works as feedback for continuous design and learning. With a broad national usage, the e-library can become a source for organizational and national learning, and a source for continuous improvement of cancer care in Sweden. CLINICALTRIAL No

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