Research Activities, November 2010: Safety and Quality of Care: Oral chemotherapy drugs not immune to medication errors

Safety and Quality of Care
Oral chemotherapy drugs not immune to medication errors

Oral chemotherapy drugs are as susceptible to medication errors as other prescription medications, a new study finds. Saul N. Weingart, M.D., Ph.D., of the Dana-Farber Cancer Institute, and colleagues studied 508 medication error incidents that occurred with oral chemotherapy drugs. They identified 99 adverse drug events; 20 were serious or life-threatening and 52 were significant. The researchers also found 322 near misses and 87 errors that posed a low risk of harming patients.

Errors occurred at every stage of the process, but most often occurred during medication ordering (47.2 percent) and dispensing (31.1 percent). Pharmacists were most likely to catch the errors (69.5 percent). Common errors included patients receiving the wrong dose (38.8 percent) or the wrong drug (13.6 percent). Another type of error, supplying patients with the wrong number of days of medication (11 percent), resulted in nearly 40 percent of incidents in which patients suffered an injury. Oral chemotherapy is especially susceptible to this type of dispensing error because of the week-on, week-off schedules and pill combinations required to deliver the correct dose. Standardizing chemotherapy regimens and improving the functionality of computerized order entry so it can be used for oral chemotherapy drugs may help curb these errors, the authors suggest.

This study was funded in part by the Agency for Healthcare Research and Quality (HS17123).

See "Medication errors involving oral chemotherapy," by Dr. Weingart, Julio Toro, R.N., B.S.N., Justin Spencer, M.P.A., and others in the May 15, 2010, Cancer 116 (10), pp. 2455-2464.

Research Activities, November 2010: Safety and Quality of Care: Oral chemotherapy drugs not immune to medication errors