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The Oncologist, Vol. 11, No. 5, 463-468, May 2006; doi:10.1634/theoncologist.11-5-463
© 2006 AlphaMed Press
Preventing Chemotherapy Errors
Lisa Schulmeister
Key Words. Chemotherapy administration • Safety • Error reporting
Correspondence:
Lisa Schulmeister, R.N., M.N., C.S., O.C.N.®, 282 Orchard Road, River Ridge, Louisiana 70123-2648, USA. Telephone: 504-739-9462 (work), 504-737-7540 (home); Fax: 504-738-2087; e-mail: LisaSchulmeister{at}hotmail.com
Received March 14, 2005;
accepted for publication March 30, 2006.
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LEARNING OBJECTIVES
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After completing this course, the reader will be able to:- Define the extent and scope of chemotherapy errors and their impact on patient care.
- Describe common types of prescribing errors.
- Recommend procedures to prevent errors in drug orders, preparation, and identification of patients.
- Identify reporting and monitoring systems both within your institution and at the government levels.
Access and take the CME test online and receive 1 AMA PRA category 1 credit at CME.TheOncologist.com
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ABSTRACT
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A large amount of information on chemotherapy error prevention is available to the practicing oncologist. However, few oncologists have the time and resources to obtain the information and evaluate the evidence. Further, much of the information is generic and does not provide specific direction on how the information can be applied in clinical practice. This manuscript reviews principles of safe chemotherapy administration, identifies key actions to prevent chemotherapy errors, and provides suggestions on how the information can be incorporated into daily practice.
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INTRODUCTION
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Your morning was unexpectedly busy. Traffic was backed up on the way to the hospital. The emergency consult for anemia has leukemic cells on the peripheral smear. Now you are rushing to the office but first have to take care of Judy Smith. Judy was admitted for treatment of refractory lymphoma and is anxious about receiving her treatment in the hospital. She read hospital errors result in more deaths than a crash of a jumbo jet every day and that 44,000–98,000 patients per year die of medical errors. You tell Judy these studies are nearly 10 years old. You and your staff are smart and care about what you do, so errors cannot happen here. While reassuring Judy, you write her orders and check her labs on the run. You hand the orders to a nurse in the hall.
In this scenario, recapitulated with variations thousands of times a day across the country, multiple sources of potential error exist. Cancer chemotherapy has a narrow therapeutic window, and patients with cancer often cannot physically tolerate mistakes. Errors in treating patients also have been associated with losses. Loss of reputation and confidence in the doctor and hospital, financial loss in the law courts, and most importantly loss for the patients. Prevention of error is a matter of remaining vigilant, having systems in place to expose mistakes, and having a culture among coworkers that error prevention is a priority. What are potential sources of vulnerability and how can we build a system that prevents errors?
- Recognizing that mistakes occur.
- Creating a culture that emphasizes error prevention with coworkers.
- Having accurate, unambiguous orders for chemotherapy.
- Continuing staff training and instantaneous access to information.
- Using systems of patient identification.
- Focusing on pharmacy concerns.
If all of the above are not in place, there are chinks in the armor of error prevention, which leaves you vulnerable.
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(1) RECOGNIZING THAT MISTAKES OCCUR
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In fact, the jumbo jet analogy allows only for 7–10 deaths per year per acute care hospital and no deaths in the outpatient or nursing home setting. This mortality statistic is believable. Furthermore, lesser injury must be much more common.
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(2) CREATING A CULTURE THAT EMPHASIZES ERROR PREVENTION WITH COWORKERS
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Assuming that you and your team are all intelligent, well trained, and motivated, still, to err is human. Though medicine is traditionally hierarchical, in reality everyone must look out for everyone else. The physician, nurse, and pharmacist should all double-check chemotherapy. Patients are better served if they know about their own treatment. No one should feel intimidated about questioning anyone else. The youngest, least experienced member of the team has to be encouraged to ask questions and look for problems. Safety is a shared challenge (Table 1
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(3) HAVING ACCURATE, UNAMBIGUOUS ORDERS FOR CHEMOTHERAPY
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Chemotherapy should not proceed if clinical information that could impact patients’ treatment and outcomes is missing. Chemotherapy order forms can be networked through computers or downloaded on handheld devices; this prevents handwriting problems and ambiguity in verbage. Included in the chemotherapy orders should be all patient data such as height, weight, body surface area, patient’s name, and route, time, dose, and date of most recent chemotherapy. Units should be spelled out, not abbreviated. Trailing zeros should not be used, because 2.0 can be mistaken for 20. Leading zeros, on the other hand, should be used to prevent misinterpretation of 0.2 as 2. Cumulative doxorubicin dose, creatinine clearance, bilirubin, albumin, and other drug-specific information can be included in the form.
Even with the best technology, your guard cannot be let down. Automated and computerized systems do not eliminate error. In its 2004 annual report, the U.S. Pharmacopeia (USP) noted that 20% of medication errors reported to the USP in 2003 were made with a computerized or automated environment. Dosing errors accounted for 49% of computerized prescriber order entry errors, and automated dispensing devices were implicated in almost 9,000 medications errors [1]. So to err is human, and mechanical as well. Despite the accuracy and facility of computers, errors that are hardwired into a computer can harm many more people than individual orders. The Institute of Safe Medication Practices (ISMP) identified numerous landmines and pitfalls associated with computerized prescriber order entry [2]. Also, many systems can be manually overridden. In a multicenter study of 3,481 computerized order entry alerts, physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts [3]. Table 2 contains recommendations for chemotherapy prescribing and preparation error prevention. These recommendations can support or be used as institutional policies and procedures, especially in smaller community-based oncology practices.
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(4) CONTINUING STAFF TRAINING AND INSTANTANEOUS ACCESS TO INFORMATION
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Staff members must be trained, and ongoing Continuing Medical Education is essential. Likewise, frequent re-emphasis of aseptic technique for procedures such as hand washing and starting i.v. infusions must be done. Moreover, reference texts, computer programs, and/or PDAs should be available at nursing stations. Protocols, particularly experimental protocols, should be readily accessible, preferably on the patient’s chart.
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(5) USING SYSTEMS OF PATIENT IDENTIFICATION
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Having two patients with common names such as Smith in the same hospital unit is a common source of error but not the only one. Five percent of the 3,871 chemotherapy errors reported to the USP involved patients inadvertently receiving the incorrect chemotherapy [4]. Schulmeister [5] found that 14% of 140 reported chemotherapy errors involved patient identification. Outpatients sometimes do not wear armbands, the best patient identification. Here is where the patient can help with telling you their name, date of birth, social security number, and other identifiers present on the chart. At least two identifiers in addition to name should be checked. Table 3 lists chemotherapy administration error prevention strategies that nurses administering chemotherapy can use as a safety checklist.
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(6) FOCUSING ON PHARMACY CONCERNS
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The hospital or office pharmacy can be organized to decrease errors. Because many oncology drugs have names that can look like or sound like other drug names, special care is required when handling these drugs (Table 4). Warning labels and signs to identify them on the shelf draw attention to possible confusion among agents with similar names, such as the vinka alkaloids, the anthracyclines, the taxanes, and actinomycin/daptomycin. Giving the therapeutic dose of vinblastine instead of vincristine could be lethal. Misreading a calendar or miscalculating the number of weeks between treatments can be avoided by scheduling several months in advance on a calendar with a copy for the patient.
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ERROR REPORTING
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Chemotherapy error reporting provides information about the types of errors that occur, their severity, and hopefully, factors that led to their occurrence. Error reports are filed internally in most health care institutions and externally to reporting organizations such as the U.S. Food and Drug Administration and USP Medication Reporting (MER) Program. The MER program, operated by the USP in cooperation with the ISMP, is a confidential national voluntary reporting program that analyzes the system causes of medication errors and identifies recommendations for prevention. Regulatory agencies and pharmaceutical manufacturers are notified of needed changes, which may include changes in product naming, packaging, and labeling. The ISMP also created the ISMP Medication Safety-Assessment® newsletters. Table 5 lists agencies that are involved in patient safety and medication error prevention.
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SUMMARY
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Chemotherapy agents have a narrow therapeutic index; even minor error spotentially can cause serious harm. Examples of chemotherapy errors include chemotherapy administration to the wrong patient, chemotherapy under- and overdosing, and incorrect route, rate, and time of administration. If treatment plans and chemotherapy orders are not verified during each treatment, errors may be repeated during subsequent chemotherapy treatments and go undetected throughout an entire treatment course. To prevent errors, chemotherapy must be viewed as "high-alert" medication. Policies and procedures need to be in place that address obtaining, storing, ordering, transcribing, dispensing, transporting, administering, and monitoring these agents.
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DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
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The author indicates no potential conflicts of interest.
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REFERENCES
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- Computer Entry a Leading Cause of Medication Errors in U.S. Health Systems. Rockville, MD: U.S. Pharmacopeia, 2004. Available at http://vocuspr.vocus.com/VocusPR30/DotNet/Newsroom/Query.aspx?SiteName=uspnews&Entity=PRAsset&SF_PRAsset_PRAssetID_EQ=95555&XSL=PressRelease&Cache=True. Accessed February 23, 2005.
- Institute for Safe Medication Practices. Landmines and Pitfalls of Computerized Prescriber Order Entry, 2002. Available at http://www.ismp.org/Newsletters/acutecare/articles/20021201.asp. Accessed February 2, 2006.
- Weingart SN, Toth M, Sands DZ et al. Physicians’ decisions to override computerized drug alerts in primary care. Arch Intern Med 2003;163:2625–2631.[Abstract/Free Full Text]
- U.S. Pharmacopeia. USP medication error analysis. USP Patient Safety CAPSLinkTM, April, 1–5, 2004.
- Schulmeister L. Chemotherapy medication errors: descriptions, severity, and contributing factors. Oncol Nurs Forum 1999;26:1033–1042.[Medline]
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[Abstract]
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