Medication Errors Among Adults and Children With Cancer in the Outpatient Setting

Walsh, Kathleen E.; Dodd, Katherine; Seetharaman, Kala; Roblin, Douglas W.; Herrinton, Lisa J.; Worley, Ann Von; Usmani, G. Naheed; Baer, David; Gurwitz, Jerry H.

doi:10.1200/jco.2008.18.6072

Cited by 172 publications

(202 citation statements)

References 25 publications

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“…The rate of these errors was higher than previously reported ones (Han et al, 2005;Young et al, 2010). The study that was including outpatient cancer patients showed that medication administration errors were done in 7% of 262 adult patients (Walsh et al, 2009). Forgetting to administer the medication is also among common medication errors (Anselmi, Peduzzi and Santos, 2007).…”

Section: 1699 Medication Errors In Chemotherapy Preparation and Admicontrasting

confidence: 50%

Medication Errors in Chemotherapy Preparation and Administration: a Survey Conducted among Oncology Nurses in Turkey

Ulaş

Sılay²,

Akıncı³

et al. 2015

Asian Pacific Journal of Cancer Prevention

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Background: Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. Materials and Methods: This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Results: Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Conclusions: Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

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Section: 1699 Medication Errors In Chemotherapy Preparation and Admicontrasting

confidence: 50%

Medication Errors in Chemotherapy Preparation and Administration: a Survey Conducted among Oncology Nurses in Turkey

Ulaş

Sılay²,

Akıncı³

et al. 2015

Asian Pacific Journal of Cancer Prevention

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“…The administration of medication is a high risk activity and drug errors are common (Walsh et al, 2009). When the medications being administered are cytotoxic the risk of harm is particularly high.…”

Section: Safe Medication Administrationmentioning

confidence: 99%

“…Patient education is a key challenge for patients receiving oral medication where a lack of concordance poses a significant risk (Jacobson et al, 2009). Many of the potential impacts of nursing relate to assessment of toxicities (Walsh et al, 2009) and are reflected in other outcomes considered in this review (e.g. nausea and vomiting, mucositis, septicaemia).…”

Section: Safe Medication Administrationmentioning

confidence: 99%

“…While drug errors are primarily related to systems failures, nurses have a role in detection and prevention before harm is done to the patient (Walsh et al, 2009). Furthermore, the administration process itself is risky requiring skilled assessment of patient fitness and patency of intravenous access (Walsh et al, 2009). Patient education is a key challenge for patients receiving oral medication where a lack of concordance poses a significant risk (Jacobson et al, 2009).…”

Section: Safe Medication Administrationmentioning

confidence: 99%

“…When the medications being administered are cytotoxic the risk of harm is particularly high. While drug errors are primarily related to systems failures, nurses have a role in detection and prevention before harm is done to the patient (Walsh et al, 2009). Furthermore, the administration process itself is risky requiring skilled assessment of patient fitness and patency of intravenous access (Walsh et al, 2009).…”

Section: Safe Medication Administrationmentioning

confidence: 99%

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Outcomes sensitive to nursing service quality in ambulatory cancer chemotherapy: Systematic scoping review

Griffiths

Richardson

Blackwell

2012

European Journal of Oncology Nursing

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Background: There is long standing interest in identifying patient outcomes that are sensitive to nursing care and an increasing number of systems that include outcomes in order to demonstrate or monitor the quality of nursing care. Objective: We undertook scoping reviews of the literature in order to identify patient outcomes sensitive to the quality of nursing services in ambulatory cancer chemotherapy settings to guide the development of an outcomes based quality measurement system. Methods: A 2 stage scoping review to identify potential outcome areas which were subsequently assessed for their sensitivity to nursing. Data sources included the Cochrane Library, Medline, Embase, the British Nursing Index, Google and Google scholar Results: We identified a broad range of outcomes potentially sensitive to nursing. Individual trials support many nursing interventions but we found relatively little clear evidence of effect on outcomes derived from a systematic reviews and no evidence associating characteristics of nursing services with outcomes. Conclusion: The purpose of identifying a set of outcomes as specifically nurse-sensitive for quality measurement is to give clear responsibility and create an expectation of strong clinical leadership by nurses in terms of monitoring and acting on results. It is important to select those outcomes that nurses have most impact upon. .Patient experience, nausea and vomiting, mucositis and safe medication administration were outcome areas most likely to yield sensitive measures of nursing service quality in ambulatory cancer chemotherapy. All authors contributed significantly to the conception writing and revision of the paper and meet the criteria for authorship. We have no conflicts of interest of which we are aware. Yours SincerelyPeter Griffiths Authors' contributionsGriffiths -design of study, review and selection of papers, drafting paper, approval of final version Richardson -design of study, drafting paper, approval of final version Blackwell -literature searching, review and selection of papers, drafting paper, approval of final version *Title Page (with authors and addresses)Outcomes sensitive to nursing service quality in ambulatory cancer chemotherapy: literature review Abstract Background: There is long standing interest in identifying patient outcomes that are

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Health Literacy–Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children

Carroll,

Johnson,

Stassun

et al. 2024

JAMA Netw Open

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ImportanceInadequate communication between caregivers and clinicians at hospital discharge contributes to medication dosing errors in children. Health literacy–informed communication strategies during medication counseling can reduce dosing errors but have not been tested in the pediatric hospital setting.ObjectiveTo test a health literacy–informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children.Design, Setting, and ParticipantsThis parallel, randomized clinical trial was performed from June 22, 2021, to August 20, 2022, at a tertiary care, US children’s hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis.InterventionsPermuted block (n = 4) randomization (1:1) to a health literacy–informed discharge medication communication bundle (n = 99) compared with standard counseling (n = 99). A study team member delivered the intervention consisting of a written, pictogram-based medication instruction sheet, teach back (caregivers state information taught), and demonstration of dosing with show back (caregivers show how they would draw the liquid medication in the syringe).Main Outcome and MeasuresObserved dosing errors, assessed using a caregiver-submitted photograph of their child’s medication-filled syringe and expressed as the percentage difference from the prescribed dose. Secondary outcomes included caregiver-reported medication knowledge. Outcome measurements were blinded to participant group assignment.ResultsAmong 198 caregivers randomized (mean [SD] age, 31.4 [6.5] years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 [95% CI, 1.0-3.6] percentage points; P &lt; .001). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group (P = .003). The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]; P = .03), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%]; P = .04), and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]; P &lt; .001). There were no differences in knowledge of medication name, indication, frequency, or storage.Conclusions and RelevanceA health literacy–informed discharge medication communication bundle reduced home liquid medication administration errors and enhanced caregiver medication knowledge compared with standard counseling. Routine use of these standardized strategies can promote patient safety following hospital discharge.Trial RegistrationClinicalTrials.gov Identifier: NCT05143047

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Medication Errors Among Adults and Children With Cancer in the Outpatient Setting

Abstract: Medication error rates are high among adult and pediatric outpatients with cancer. Our findings suggest some practical targets for intervention, including improved communication about medication administration in the clinic and home.

Cited by 172 publications

References 25 publications

Medication Errors in Chemotherapy Preparation and Administration: a Survey Conducted among Oncology Nurses in Turkey

Medication Errors in Chemotherapy Preparation and Administration: a Survey Conducted among Oncology Nurses in Turkey

Outcomes sensitive to nursing service quality in ambulatory cancer chemotherapy: Systematic scoping review

Health Literacy–Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children

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