ASHP Guidelines on Preventing Medication Errors with Antineoplastic Agents

Kohler, David R.; Montello, Michael; Goldspiel, Barry R.; DeChristoforo, Robert; Huntley, Carl; High, Joe; Fallavollita, Alfred; Shalabi, Aiman; Meadows, Beverly; Green, Laurence; Ignoffo, Robert J.

doi:10.1093/ajhp/59.17.1648

Cited by 94 publications

(8 citation statements)

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“…Chemotherapy-related medication-error prevention is a high priority within pharmacies and hospitals. There are international clinical guidelines that report strategies for preventing medication errors 7–11. Recent guidelines from the American Society of Health-System Pharmacists acknowledge that technologies to automate the preparation of chemotherapy are emerging10 and these include chemotherapy compounding workflow technology solutions consisting of chemotherapy workflow software and robotic compounding systems.…”

Section: Introductionmentioning

confidence: 99%

Automated compounding technology and workflow solutions for the preparation of chemotherapy: a systematic review

Batson¹,

Mitchell

Lau

et al. 2019

Eur J Hosp Pharm

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ObjectivesThe current systematic review (SR) was undertaken to summarise the published literature reporting the clinical and economic value of automation for chemotherapy preparation management to include compounding workflow software and robotic compounding systems.MethodsLiterature searches were conducted in MEDLINE, Embase and the Cochrane Library on 16 November 2017 to identify publications investigating chemotherapy compounding workflow software solutions used in a hospital pharmacy for the preparation of chemotherapy.Results5175 publications were screened by title and abstract and 18 of 72 full publications screened were included. Grey literature searching identified an additional seven publications. The SR identified 25 publications relating to commercial technologies for compounding (Robotic compounding systems: APOTECAchemo (n=12), CytoCare (n=5) and RIVA (n=1); Workflow software: Cato (n=6) and Diana (n=1)). The studies demonstrate that compounding technologies improved accuracy in dose preparations and reduced dose errors compared with manual compounding. Comparable levels of contamination were reported for technologies compared with manual compounding. The compounding technologies were associated with reductions in annual costs compared with manual compounding, but the impact on compounding times was not consistent and was dependent on the type of compounding technology.ConclusionsThe published evidence suggests that the implementation of chemotherapy compounding automation solutions may reduce compounding errors and reduce costs; however, this is highly variable depending on the form of automation. In addition, the available evidence is heterogeneous, sparse and inconsistently reported. A key finding from the current SR is a ‘call to action’ to encourage pharmacists to publish data following implementation of chemotherapy compounding technologies in their hospital, which would allow for evidence-based recommendations on the benefits of chemotherapy compounding technologies.

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Section: Introductionmentioning

confidence: 99%

Automated compounding technology and workflow solutions for the preparation of chemotherapy: a systematic review

Batson¹,

Mitchell

Lau

et al. 2019

Eur J Hosp Pharm

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“…The 143 reports were coded to understand medication-use process stage, medication error type, and contributing factor emerging themes, as described in the codebook in Appendix C. The medication-use process stages were modeled after the American Society of Hospital Pharmacists (ASHP) medication use categories. 35 The medication error type was adopted from the National Coordinating Council for Medication Error Reporting Contributing factor emerging themes (e.g., care coordination and information exchange) and subthemes (e.g., incomplete information flow, handoff ) were identified through an iterative process of reviewing vancomycin-related reports. 34 The free-text narrative served as the foundation for coding.…”

Section: Analysis Methodsmentioning

confidence: 99%

Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports

et al. 2020

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Intravenous (IV) vancomycin is one of the most commonly used antibiotics in U.S. hospitals. There are several complexities associated with IV vancomycin use, including the need to have an accurate patient weight for dosing, to provide close monitoring to ensure appropriate drug levels, to monitor renal function, and to continue delivery of the medication at prescribed intervals. There are numerous healthcare system factors, including workflow processes, policies, health information technology, and clinical knowledge that impact the safe use of IV vancomycin. Past literature has identified several safety hazards associated with IV vancomycin use and there are some proposed solutions. Despite this literature, IV vancomycin–related safety issues persist. We analyzed patient safety event reports describing IV vancomycin–related issues in order to identify where in the medication process these issues were appearing, the type of medication error associated with each report, and general contributing factor themes. Our results demonstrate that recent safety reports are aligned with the issues already identified in the literature, suggesting that improvements discussed in the literature have not translated to clinical practice. Based on our analysis and current literature, we have developed a shareable infographic to improve clinician awareness of the complications and safety hazards associated with IV vancomycin and a self-assessment tool to support identification of opportunities to improve patient safety during IV vancomycin therapy. We also recommend development of clear guidelines to optimize health information technology systems to better support safe IV vancomycin use.

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“…Thus, even minor deviations from the intended dose can result in significant or life-threatening effects (3). The prevalence of chemotherapy errors in human medicine is not known as most published literature focuses on individual case reports and not encompassing cohort studies (4). Nevertheless, several agencies have attempted to decrease the probability of a chemotherapy OD by outlining standard practices to reduce the error rate (4,5).…”

Section: Introductionmentioning

confidence: 99%

A Retrospective Evaluation of Chemotherapy Overdoses in Dogs and Cats

et al. 2021

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Chemotherapy overdoses (ODs) are severe complications that can occur following the use of antineoplastics. However, little is known about chemotherapy ODs in veterinary medicine. The goals of this retrospective study were to report the occurrence, type, and cause of known chemotherapy ODs in companion animal medicine. The American College of Veterinary Internal Medicine oncology and internal medicine listservs were solicited for chemotherapy OD cases in dogs and cats. An OD was defined as administration of a chemotherapy dose 10% higher than intended, or at a shorter interval than planned. Twelve non-anthracycline ODs in 11 dogs, and 3 cat ODs, were collected. Overdoses in dogs included carboplatin, cyclophosphamide, L-asparaginase, lomustine, mustargen, vincristine, and vinorelbine. The cat ODs included doxorubicin and vincristine. In dogs, the median OD was 2.1x (range: 1.2–10x) the intended dose. All dogs survived the OD and developed a variety of gastrointestinal and hematologic toxicities of varying grades. Both cats with a 2.4x vincristine OD died despite supportive care. The cat who received a 2x OD of doxorubicin survived the event, experiencing Veterinary Cooperative Oncology Group–common terminology criteria for adverse events (VCOG) grade I thrombocytopenia and anemia, and VCOG grade II neutropenia. Chemotherapy ODs appear to be rare in veterinary medicine and are typically 2–3xs the intended dose. Clinical effects include VCOG grade I and II gastrointestinal distress and VCOG grade III and IV hematologic effects. With appropriate supportive care, most patients will survive the event. Life-threatening events are more common in cats following vincristine ODs.

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ASHP Guidelines on Preventing Medication Errors with Antineoplastic Agents

Cited by 94 publications

References 0 publications

Automated compounding technology and workflow solutions for the preparation of chemotherapy: a systematic review

Automated compounding technology and workflow solutions for the preparation of chemotherapy: a systematic review

Identifying Safety Hazards Associated With Intravenous Vancomycin Through the Analysis of Patient Safety Event Reports

A Retrospective Evaluation of Chemotherapy Overdoses in Dogs and Cats

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