Medication errors in a cohort of pediatric patients with acute lymphoblastic leukemia on remission induction therapy in a tertiary care hospital in Mexico

Abstract

Introduction Medication errors (MEs) are the main type of preventable adverse events in medical care, as well as safety indicators in the medication processes. Advances in the quality of care in pediatric acute lymphoblastic leukemia (ALL) have enabled to improve clinical outcomes. However, ME epidemiology in pediatric oncology is still incipient in developing countries. In view of this, the objectives of this study were to estimate the incidence of MEs, determine their types and consequences, as well as their preventability in the induction treatment of children with ALL at Hospital Infantil de Mexico Federico Gómez. Methods We reviewed the remission‐induction chemotherapy records of children with ALL between January 2015 and December 2017. A two‐phase review was carried out for ME identification and verification. The consequences of errors were determined by agreement between reviewers. Results We reviewed 1762 chemotherapy orders involving 181 children. MEs were observed in 16.9% of orders and in 57.5% of patients. Prescription errors were the most common (93.3%), with wrong dose errors (90.2%) being predominant. Only 3.7% of wrong dose errors were intercepted, while 12.2% of the children experienced adverse drug events (ADEs) preceded by some wrong dose error. Conclusions MEs were common, since they occurred in 57.5% of children with ALL on induction treatment and involved 16.5% of chemotherapy orders. Only 3.7% of MEs were intercepted, while 12.2% of children had ADEs related to overdose. Measures are required to prevent calculation error in prescriptions, as well as training of the nursing staff to intercept MEs.

Incidence, severity, and preventability of adverse events during the induction of patients with acute lymphoblastic leukemia in a tertiary care pediatric hospital in Mexico

“…In a previous peer-reviewed publication, we used information on chemotherapy from this cohort to study MEs [18]. We emphasize that the study focused on MEs and the present work on AEs have different purposes: the former focused on the quality of the chemotherapy medication process, and the current work focuses on the preventability of AEs related to all healthcare-related interventions (drugs, procedures and hospital care).…”

“…However, to the best of our knowledge, no description of AEs has been carried out in Mexico with a focus on processes of care and preventability in children with ALL, despite being important elements for patient safety. The scant evidence is on ADE related to chemotherapy medication errors (ME) [18], but the extent of AEs goes beyond drugs. Therefore, the purpose of this work is to comprehensively describe the incidence, type, severity, and preventability of AEs that occur in pediatric patients with ALL during the remission induction phase in a tertiary care hospital of Mexico City.…”

Fatores Associados Ocorrência De Erros No Preparo E Administração De Medicamentos Intravenosos: Revisão Sistemática Da Literatura

“…Sendo o erro mais frequente a interrupção durante a administração do medicamento. Vázquez-Cornejo et al, (2019), constatou que o erro na terapia venosa mais prevalente foram o de prescrição com predominância de erros de dose incorretos na administração de medicamentos. No que se refere aos fatores associados Suclupe et al, (2020), constatou que a sobrecarga de trabalho dos profissionais é influência para a ocorrência de erros na terapia medicamentosa, principalmente na interrupção da administração de medicamentos.…”

Prevalence and factors contributing to medication errors in a referral hospital in Iran: A retrospective study

“…The medication error represents a mounting medical concern worldwide; moreover is a critical area of interest within the field of Indicators of quality of care principles and the Hospital Safety Index [1] . In most cases, a medication error is defined as any inappropriate drug administration that may cause harm to the patient, while preventable and equally occur under the supervision of the medical team [2] .…”

“…Methods Design and participants: The study population was limited to the employees of the mentioned hospital. The design of the type of errors was based on several similar studies [1,7,8] . The different departments were divided into four groups, including General wards, Cardiology wards, Special wards, and Non-clinical departments.…”