Characteristics of medication errors with parenteral cytotoxic drugs

Abstract

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.

Medication safety incidents in paediatric oncology after electronic medication management system implementation

“…Incident reports offer a valuable bird's eye view of the events those working at the front line consider important for the safety of patients. Our analysis showed that medication safety incidents in paediatric oncology occurred in prescribing, dispensing, administration and monitoring tasks, consistent with those found in adult oncology and other clinical settings (Ferner & Aronson, , ; Fyhr & Akselsson, ; Schwappach & Wernli, ). However, they also occurred in other tasks, those related to care coordination, to the handling or storing of medications and to children or families handling medications.…”

Nationwide Evaluation of Day‐to‐Day Clinical Pharmacists’ Interventions in German Hospitals

“…On the other hand, MEs and subsequent PIs related to drug preparation might be recorded directly in the documents linked to the production process and/or elsewhere in the central pharmacy within a quality‐assured process. Nevertheless, it is well known that prescribing errors and subsequent PIs also exist in the group of cytotoxic drugs . Furthermore, because ward‐based clinical pharmacists are not yet established and accepted nationwide in Germany, the need for documentation of their work is of high priority—but is not obligatory—to demonstrate the additional value.…”

Emergency use of uridine triacetate for the prevention and treatment of life‐threatening 5‐fluorouracil and capecitabine toxicity

“…In this instance, a 43‐year‐old patient received a 5250‐mg dose of 5‐FU over 4 hours instead of the intended 4 days and died 22 days later from toxicity even after aggressive supportive care. Accidental overdoses with 5‐FU continue to be a significant problem …”

“…Accidental overdoses with 5-FU continue to be a significant problem. [2][3][4][5] Capecitabine is an orally bioavailable prodrug that is converted by 3 sequential enzymatic steps to yield 5-FU. 6 The most common toxicities caused by both agents are consequences of cytotoxic damage to rapidly dividing cells, and they include mucositis, diarrhea, and cytopenias.…”