Errors involving pediatric patients receiving chemotherapy: a literature review

Preventing Medication Errors with Antineoplastic Agents, Part 2

Goal

The goal of this program is to present practical ways to prevent medication errors with antineoplastic agents, identify common types of medication errors, and describe a system for reducing and responding appropriately to antineoplastic medication errors.

Objectives

At the completion of this program the participant will be able to: 1. Describe the scope and impact of medication errors 2. Define common terms used in medication error literature. 3. List four common types of prescribing errors made with antineoplastic agents. 4. Identify steps where medication errors may occur in the drug ordering, preparation, and administration process. 5. Describe ways to prevent errors at each step of the medication use process. 6. Recommend a procedure for reporting and monitoring antineoplastic medication errors within the institution. 7. Describe a system for the nonpunitive management of antineoplastic medication errors in health care systems.

Preventing Medication Errors with Antineoplastic Agents, Part 1

Goal — The goal of this program is to present practical ways to prevent medication errors with antineoplastic agents, identify common types of medication errors, and describe a system for reducing the incidence of medication errors and responding appropriately to antineoplastic medication errors.

Objectives — At the completion of this program, the participant will be able to:

1. Describe the scope and impact of medication errors

2. Define common terms used in medication error literature.

3. List four common types of prescribing errors made with anti-neoplastic agents.

4. Identify steps where medication errors may occur during the drug ordering, preparation, and administration process.

5. Describe ways to prevent errors at each step of the medication use process.

6. Recommend a procedure for reporting and monitoring antineoplastic medication errors within the institution.

7. Describe a system for the non-punitive management of antineoplastic medication errors in health care systems.

Risk management of in-hospital administration of anticancer drugs: impact of Raccomandazione 14 from the Italian Ministry of Health

PURPOSE

The different stages of antineoplastic agent management build up a complex process, from supply to prescription, preparation, and administration. All steps in this process must be carefully monitored in order to control/reduce the risk of errors that can impact on patient safety. This work overviews the prevention of medication errors in oncology, including regulatory and legislative frameworks with specific reference to the Raccomandazione 14 (Recommendation 14) issued by the Italian Ministry of Health.

METHODS

We searched the literature for types, causes, and contributing factors of medication errors during administration of antineoplastic agents. International guidelines and recommendations were examined, with specific focus on the Raccomandazione 14.

RESULTS

Medication errors may occur along the entire therapeutic process, involving physicians, pharmacists, nurses, and other healthcare providers. A computerized prescribing system combined with a clinical decision support system helps physicians in minimizing prescribing errors. Hospital pharmacists play a crucial role in preventing inpatient prescription errors and in managing storage, dispensing, and compounding of the anticancer drugs. The Italian Ministry of Health issued the Raccomandazione 14 to provide the Italian health system with shared univocal procedures for anticancer drug supply, compounding, storage, prescription, and administration. Other themes addressed are patient and family involvement, humanization of cancer care, and training and accountability of the personnel involved.

CONCLUSIONS

The most effective means of managing the risk of medication errors remains prevention, which lies on the systematic documentation of medication errors reporting systems. All professionals of the healthcare team involved in anticancer drug management and the institutional authorities are called upon to strive for any possible effort to prevent and eliminate medication errors.

Updating a survey for medication error prevention

Objective. Literature review and subsequent gap analysis of the current Alberta Cancer Board (ACB) Oncology Medication Error Prevention Status Survey and the incorporation of new information to aid in the development of a stronger medication error prevention system.

Design. Gap analysis based on a literature review was performed on the current ACB survey via a literature search of EMBASE, Medline, and the Cochrane Database of Systematic Reviews. The completed survey was sent to 17 ACB sites for feedback.

Setting. The ACB in the Canadian province of Alberta, which includes 2 public tertiary centers and 15 associated community satellite sites based around the province in existing hospitals.

Main outcome measures. Gaps in the current medication error prevention survey requiring improvement as compared to current literature, with emphasis on pharmacy.

Results. All sections required additional information and two new sections were created to reduce the gaps in organizational commitment and environmental concerns. Of the 17 ACB sites, 13 sites responded to the survey and 11 responded to the questionnaire. Out of a possible 154 questions, 64 questions had at least one site disagree and 20 questions had more than one site disagree.

Conclusion. Through a literature review and gap analysis, the current ACB Oncology Medication Error Prevention Status Survey was improved. Responses to changes have not only demonstrated the need for a survey of this kind, but also the need for periodic updates of the information in the survey.

The impact of recent vincristine on human hematopoietic progenitor cell collection in pediatric patients with central nervous system tumors

BACKGROUND

Central nervous system (CNS) malignancies represent 20% of all childhood cancers. To improve outcomes in infants and children with high-risk disease, treatment can include adjuvant chemotherapy and early autologous peripheral blood human progenitor cell collection (AHPCC), followed by high-dose chemotherapy and stem cell rescue. In many protocols, postoperative chemotherapy includes the administration of weekly vincristine (VCR) between induction chemotherapy cycles, regardless of scheduled AHPCC. We observed anecdotal AHPCC failures in children receiving midcycle VCR (MC-VCR).

STUDY DESIGN AND METHODS

The study was an 8-year retrospective chart review of all children with a CNS malignancy and who underwent AHPCC. Information included patient demographic and clinical data, mobilization regimen, VCR administration, product yields, infusion toxicity, and patient charges. Data were analyzed relative to MC-VCR administration. Graphics and statistical analysis (t-test, chi-square, linear regression) were performed with commercial software.

RESULTS

Twenty-four patients and 47 AHPCCs were available for analysis. Nine patients (37%) received MC-VCR within 7 days of scheduled AHPCC. MC-VCR was associated with delayed marrow recovery (17.9 days vs. 14.9 days, p=0.0012), decreased median peripheral CD34 counts (75 × 10(6) CD34/L vs. 352 × 10(6) CD34/L, p=0.03), decreased median CD34 yields (2.4 × 10(6) CD34/L vs. 17.8 × 10(6) CD34/kg, p=0.08), more AHPCCs per mobilization (2.9 vs. 1.1, p=0.01), and an increased rate of remobilization (33% vs. 6%). Mean patient charges were 2.5× higher in patients receiving MC-VCR than controls (p=0.01).

CONCLUSION

MC-VCR should be withheld before scheduled AHPCC to optimize CD34 collection.

High-alert medications for pediatric patients: an international modified Delphi study

BACKGROUND

The available knowledge about high-alert medications for children is limited. Because children are particularly vulnerable to medication errors, a list of high-alert medication specifically for children would help to develop effective strategies to prevent patient harm. Therefore, we conducted an international modified Delphi study and validated the results with reports on medication incidents in children based on national data.

OBJECTIVE

The objective of this study was to generate an internationally accepted list of high-alert medications for a pediatric inpatient population from birth to 18-years old.

RESULTS

The rating panel consisted of 34 experts from 13 countries. In total, 14 medications and 4 medication classes were included with the predefined level of consensus of 75%. The high-alert medications were: amiodarone, digoxin, dopamine, epinephrine, fentanyl, gentamycin, heparine, insulin, morphine, norepinephrine, phenytoin, potassium, propofol and tacrolimus. The high-alert medication classes included in the final list were: chemotherapeutic drugs, immunosuppressive medications, lipid/total parenteral nutrition and opioids.

CONCLUSION

An international group of experts defined 14 medications and 4 medication classes as high-alert for children. This list might be helpful as a starting point for individual hospitals to develop their own high-alert list tailored to their unique situation.

Accidental overdose of intrathecal cytarabine in children

OBJECTIVE

To report 2 cases of intrathecal cytarabine overdose in children with cancer, neither of whom underwent cerebrospinal fluid (CSF) exchange per current recommendations or developed apparent toxicity related to the event.

CASE SUMMARY

A 17-year-old female with newly diagnosed acute myeloid leukemia received 177 mg of intrathecal cytarabine rather than the appropriate dose of 70 mg. She was monitored closely with no apparent toxicity from the event. A 4-year-old boy with newly diagnosed precursor B-cell acute lymphoblastic leukemia received 175 mg of intrathecal cytarabine rather than the appropriate dose of 70 mg. CSF was immediately withdrawn and intrathecal hydrocortisone was instilled for possible antiinflammatory effect. He developed no apparent toxicity from the event.

DISCUSSION

Cytarabine is an important chemotherapeutic agent in the treatment of leukemia. One case report of intrathecal cytarabine overdose was identified in the literature, which recommended CSF exchange as management. Neither child in our report underwent CSF exchange or developed apparent toxicity related to the event. Institutional changes were made in both cases to prevent similar events.

CONCLUSIONS

These cases demonstrate that measures such as CSF exchange are not uniformly required for cytarabine overdose.

Errors involving patients receiving intrathecal chemotherapy

Errors involving patients receiving intrathecal chemotherapy are a significant problem in oncology. Despite the improvement in the management of antineoplastic agents, unintentional intrathecal administration of chemotherapic drugs that are indicated only for systemic administration or intrathecal overdose of drugs regularly used for intrathecal chemotherapy, continue to occur. These events can result in severe neurotoxicity, usually fatal in outcome. We review reported cases of medication errors in intrathecal administration of chemotherapy described in the literature. Diverse rescue therapies have been proposed but the most effective means of managing these errors remains prevention.

Medication errors in pediatric inpatients: prevalence and results of a prevention program

OBJECTIVE

The objective of this study was to assess the prevalence and characteristics of medication errors in pediatric and neonatal inpatients and to measure the impact of interventions to reduce medication errors.

METHODS

A preintervention and postintervention cross-sectional study was conducted of a sample of prescriptions that were ordered by physicians and medications that were administered by nurses to patients at the NICU, PICU, and general pediatric settings at the Hospital Italiano de Buenos Aires Department of Pediatrics in 2002 and 2004. Number and type of errors, time shift on which they occurred, and whether they had any kind of adverse event on the patient were recorded. Medication errors were stratified according to physicians' and nurses' status. Several interventions, including incorporating a positive safety culture without a punitive management of errors and specific prescribing and drug-administration recommendations were implemented between the 2 phases of the study.

RESULTS

A total of 590 prescriptions and 1174 drug administrations for 95 patients in the first phase of the study and 1144 prescriptions with 1588 drug administrations for 92 patients in the second phase were evaluated. The prevalence of medication error rate in the second phase was 7.3% (199 of 2732) and 11.4% (201 of 1764) in the first phase. The risk difference was -4.1%.

CONCLUSIONS

The development of a program mainly centered on the promotion of a cultural change in the approach to medical errors can effectively diminish medication errors in neonates and children.

Characteristics of pediatric chemotherapy medication errors in a national error reporting database

BACKGROUND

Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors.

METHODS

The authors queried the United States Pharmacopeia MEDMARX database, a national, voluntary, Internet-accessible error reporting system, for all error reports from 1999 through 2004 that involved chemotherapy medications and patients aged <18 years.

RESULTS

Of the 310 pediatric chemotherapy error reports, 85% reached the patient, and 15.6% required additional patient monitoring or therapeutic intervention. Forty-eight percent of errors originated in the administering phase of medication delivery, and 30% originated in the drug-dispensing phase. Of the 387 medications cited, 39.5% were antimetabolites, 14.0% were alkylating agents, 9.3% were anthracyclines, and 9.3% were topoisomerase inhibitors. The most commonly involved chemotherapeutic agents were methotrexate (15.3%), cytarabine (12.1%), and etoposide (8.3%). The most common error types were improper dose/quantity (22.9% of 327 cited error types), wrong time (22.6%), omission error (14.1%), and wrong administration technique/wrong route (12.2%). The most common error causes were performance deficit (41.3% of 547 cited error causes), equipment and medication delivery devices (12.4%), communication (8.8%), knowledge deficit (6.8%), and written order errors (5.5%). Four of the 5 most serious errors occurred at community hospitals.

CONCLUSIONS

Pediatric chemotherapy errors often reached the patient, potentially were harmful, and differed in quality between outpatient and inpatient areas. This study indicated which chemotherapeutic agents most often were involved in errors and that administering errors were common. Investigation is needed regarding targeted medication administration safeguards for these high-risk medications.

Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital

BACKGROUND

Medication management is a complex, multifaceted system. Prescribing errors occur upstream in the process, and as such, their effects can be perpetuated, and sometimes even exacerbated, in subsequent steps. These errors place patients at risk of adverse drug events. Children, especially young infants, are at particular risk because of their size, unique physiology, and immature ability to metabolize drugs.

OBJECTIVE

The purpose of this study was to reduce the risk of harm to children resulting from prescribing errors.

METHODS

We sequentially implemented patient safety initiatives over a 1-year time frame at a pediatric tertiary care academic facility. The initiatives included an educational Web site with competency examination, distribution of a personal digital assistant-based standardized dosing reference, a zero-tolerance policy for incomplete or incorrect medication orders, prescriber performance feedback, and presentation of outcome data at citywide grand rounds. A total of 8718 orders were collected and analyzed to assess the impact of these initiatives.

RESULTS

The absolute risk reduction from prescribing errors was 38 per 100 orders, with a relative risk reduction of 49%. Web-based education with point-of-care drug references and a zero-tolerance policy for incomplete or incorrect orders were most effective in decreasing potential adverse drug events. Documentation of appropriate weight-based dosing and indication for therapy increased by 24% and 42%, respectively.

CONCLUSIONS

Process-improvement initiatives focusing on prescriber education and behavior modification can reduce the risk of harm to pediatric patients from prescribing errors.

Medication safety in the ambulatory chemotherapy setting

BACKGROUND

Little is known concerning the safety of the outpatient chemotherapy process. In the current study, the authors sought to identify medication error and potential adverse drug event (ADE) rates in the outpatient chemotherapy setting.

METHODS

A prospective cohort study of two adult and one pediatric outpatient chemotherapy infusion units at one cancer institute was performed, involving the review of orders for patients receiving medication and/or chemotherapy and chart reviews. The adult infusion units used a computerized order entry writing system, whereas the pediatric infusion unit used handwritten orders. Data were collected between March and December 2000.

RESULTS

The authors reviewed 10,112 medication orders (8008 adult unit orders and 2104 pediatric unit orders) from 1606 patients (1380 adults and 226 pediatric patients). The medication error rate was 3% (306 of 10,112 orders). Of these errors, 82% occurring in adults (203 of 249 orders) had the potential for harm and were potential ADEs, compared with 60% of orders occurring in pediatric patients (34 of 57 orders). Among these, approximately one-third were potentially serious. Pharmacists and nurses intercepted 45% of potential ADEs before they reached the patient. Several changes were implemented in the adult and pediatric settings as a result of these findings.

CONCLUSIONS

In the current study, the authors found an ambulatory medication error rate of 3%, including 2% of orders with the potential to cause harm. Although these rates are relatively low, there is clearly the potential for serious patient harm. The current study identified strategies for prevention.

Treatment-related death in childhood acute lymphoblastic leukaemia in the Nordic countries: 1992-2001

Despite continuously more successful treatment of childhood acute lymphoblastic leukaemia (ALL), 2-5% of children still die of other causes than relapse. The Nordic Society of Paediatric Haematology and Oncology-ALL92 protocol included 1652 patients < or =15 years of age with precursor B- and T-cell ALL diagnosed between 1992 and 2001. Induction deaths and deaths in first complete remission (CR1) were included in the study. A total of 56 deaths (3%) were identified: 19 died during induction (1%) and 37 in CR1 (2%). Infection was the major cause of death in 38 cases. Five patients died of early death before initiation of cytotoxic therapy. Five patients died because of toxicity of inner organs and one of accidental procedure failures. Seven patients died of complications following allogenic haematopoietic stem cell transplantation (HSCT) in CR1. Girls were at higher risk of treatment-related death (TRD) [relative risk (RR) = 2.2; 95% confidence interval (CI(95%)): 1.2-4.0, P < 0.01], mostly because of infections. Risk of TRD was also higher in children with Down syndrome (RR = 4.5; CI(95%): 2.0-10.2, P < 0.00). In conclusion, 3% of children with ALL died of TRD, with bacterial infections as the most common cause of death. Girls and Down syndrome patients had a higher risk of TRD. Infections still remain a major challenge in childhood ALL.

A case of vinblastine overdose managed with plasma exchange

Severe, life-threatening toxicity may be caused by errors in chemotherapy administration. To contribute with some useful information on drug-induced toxic effects and salvage therapy, we report a case of vinblastine (VBL) overdose (25 mg/m(2)) in a 12-year-old child affected by an end-stage metastatic primitive neuroectodermal tumor. Early signs of toxicity were acute, severe musculoskeletal pain and fever. This was followed by intestinal hypotonia, severe esophagitis, and peripheral neuropathy. Two consecutive plasma exchange procedures were performed at 4 and 18 hr after the administration of the overdose of VBL. The overall toxicity this child experienced was much less severe than expected; this finding, in combination with the known pharmacokinectis data of VBL in children, made us hypothesize that plasma exchange might have had a role in lowering the side effects of drug over dosage.

Chemotherapy error reduction: a multidisciplinary approach to create templated order sets

More than 48,000 newly diagnosed cancer patients can expect to have some adverse events related to their care each year. Historically, 20% of these adverse events have been medication related, and two thirds have been thought to be preventable. Since the majority of these errors occurred during the order writing process, the prioritized changes made at the joint pediatric program for Children's Hospital, Boston, and Dana-Farber Cancer Institute have been the initiation of templated orders and the development of a computerized order entry system. The goal of this initiative was to decrease errors related to chemotherapy administration by creating legible, complete, clearly defined order sets, and at the same time, to make order writing and reviewing more efficient. Chemotherapy templates were created using a consistent format and a rigorous multidisciplinary review process. Each order set includes the following: identification of the patient and cycle of chemotherapy to be given, criteria necessary to receive chemotherapy, chemotherapy orders with modifications if appropriate, and supportive care orders. Templated order sets have reduced the duplication of work efforts by significantly reducing the number of changes made during the order verification process; orders are more complete, and standardization has occurred.

Medication errors in pediatrics--the octopus evading defeat

Medication errors have come to the forefront in healthcare and oversight organizations as well as to the public over the past several years. There has been an increasing focus on this area of patient care requiring more intensive evaluation and intervention to prevent these errors. Although it is difficult to ascertain the true occurrence of medication errors, they may occur as frequently as once in every 20 orders. Children are at higher risk for medication errors and adverse drug events for numerous reasons. Not only is there great variability in weight and body surface area in this population, there is also significant differences in the pharmacokinetics and pharmacodynamics of many medications when compared to adults. In addition, our knowledge of pharmacogenetics and phenotypic ontogeny must be applied. Sources of medication errors are identified, and specific examples and solutions to improve medication use in children are provided. It is critical to have 1) personnel trained in pediatrics to prescribe, prepare, dispense and administer medications, 2) a quality review system in place to review drug use and medication errors, and 3) to implement computerized physician order entry with decision support and other tools in the next decade to improve pharmacologic therapy for pediatric patients.

Improving pediatric chemotherapy safety through voluntary incident reporting: lessons from the field

BACKGROUND

A multidisciplinary team within Vanderbilt Children's Hospital (VCH) designed, developed, and implemented a pediatric chemotherapy incident reporting and improvement system (CIRIS) for pediatric oncology nurse and pharmacists. The aim of this collaboration was to improve pediatric chemotherapy by translating recommendations made by the Institute of Medicine into an operational safety improvement system that is embedded into daily care processes.

METHODS

CIRIS improves chemotherapy safety by linking two distinct components: (a) a technical component that uses desktop, laptop, and portable wireless handheld computers to interface the Web-based software application for point-of-care incident reporting and on-demand retrieval of patient support information, and (b) a human component that performs process analysis, data reporting, and clinical improvement. This integrated system facilitates and supports a blame-free culture for reporting of near misses and preventable adverse drug events.

RESULTS

Between February 8, 2002, and March 9, 2003, pediatric oncology nurses and chemotherapy pharmacists electronically reported 97 chemotherapy-related incidents associated with 96 unique patients. Ordering errors were the most commonly reported incidents. CIRIS improved reporting performance demonstrated using the conventional paper-based reporting system.

Assessing medication prescribing errors in pediatric intensive care units

OBJECTIVE

To evaluate a matrix for determining the predominant type, cause category, and rate of medication prescribing errors, and to explore the effectiveness of hospital-based improvement initiatives among pediatric intensive care units (PICUs).

DESIGN

This study involved the prospective identification of medication errors for categorization and evaluation by using a matrix methodology. A pretest-posttest design without a control group was used to explore the impact of initiatives employed to reduce medication error rates and severity.

SETTING

PICUs in nine freestanding, collaborating tertiary care children's hospitals that participated in both baseline and postintervention analyses.

METHODS

We evaluated 12,026 PICU medication orders at baseline and 9,187 orders postintervention for prescribing errors, excluding resuscitation orders. A standardized tool and process captured error type, cause category, and severity for 2 wks before and after intervention. Three levels of error detection were used and included pharmacy order entry, PICU nurse order transcription, and team-based overview. Site-specific interventions were implemented, which included predominantly provider education as well as informational (47%) and dosing "assists" via preprinted orders, forcing functions, or prompts (39%).

RESULTS

Of baseline orders, 11.1% had at least one prescribing error. The interception of prescribing errors improved 30.9% (1.6% of all orders at baseline, 2.0% post intervention). Preventable adverse drug events were uncommon (0.6% of all medication errors) and of low severity at baseline; most were wrong dose errors. The implementation of improvement initiatives, specific for each facility, resulted in a 31.6% reduction in prescribing errors from 11.1% to 7.6%. However, site results varied considerably.

CONCLUSIONS

A benchmark for medication prescribing errors in the PICU was identified among nine children's hospitals. The methodology was successful in accounting for site-specific differences with regard to identifying and documenting errors as well as reporting results of improvement initiatives. Furthermore, the methodology employed was generalizable in the identification of predominant prescribing error types, which helped to track individual hospital improvement initiative development and implementation. Overall improvement in prescribing error rates was noted; however, considerable variation in the success of improvement initiatives was noted and bears further attention.

What do we know about medication errors in inpatient psychiatry?

BACKGROUND

Adverse drug events (ADEs) have been implicated as a cause of substantial morbidity and mortality. Psychiatrists have successfully characterized one category of ADE--adverse drug reactions (ADRs), which have been studied from a medication-specific psychopharmacology frame of reference. The literature on ADEs, both preventable and nonpreventable, was reviewed within the broader patient safety framework.

METHODS

English-language studies involving ADEs and medication errors in psychiatry for 1996 through 2003 were identified on MEDLINE and by using a hand search of bibliographies.

RESULTS

Few reports on the incidence and characteristics of medication errors in psychiatric hospitals could be found. Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture. PREVENTION STRATEGIES: Application of a systems-oriented approach to ADE reduction and the promotion of a nonpunitive culture are essential. Clinical and pharmacy staff could monitor the literature for published reports of preventable adverse events and review those reports in multidisciplinary team meetings.

CONCLUSIONS

Psychiatry would benefit from learning about the terminology used in describing medication errors and ADEs. Relatively few data are available regarding the frequency and consequences of medication errors in psychiatry; more research is needed.

A chemotherapy incident reporting and improvement system

BACKGROUND

The Vanderbilt University Medical Center (VUMC) has designed and deployed the Chemotherapy Incident Reporting and Improvement System (CIRIS), which is embedded into daily care processes. The system uses commercial information technologies, including handheld computers, to create a mobile Web-based chemotherapy incident reporting system for nurses and pharmacists. Two phases--(1) development and implementation of the CIRIS incident reporting safety registry and (2) development of the handheld-computer interface--were implemented. The final phase entails integration of the computerized order entry system into the front end of the CIRIS architecture. The voluntary incident reporting system data are stored over time for use by the multidisciplinary safety improvement team.

RESULTS

Staff buy-in has been demonstrated by increased reporting rates, the high number of provider-initiated improvements made to the reporting tool during the first year of implementation, and specific chemotherapy safety interventions conceived from analysis of the reported data.

CONCLUSION

The CIRIS model for pediatric chemotherapy safety improvement has been implemented in the inpatient setting but could easily be configured for a variety of other clinical applications in inpatient or outpatient settings. CIRIS has been effective, especially in the chemotherapy pharmacy, where incident reporting has increased dramatically.

Intrathecal vincristine: fatal myeloencephalopathy despite cerebrospinal fluid perfusion

BACKGROUND

Vincristine, an antineoplastic agent, must never be injected intrathecally because of its devastating neurotoxic effects, which are usually fatal. We report a case of fatal myeloencephalopathy secondary to inadvertent intrathecal administration of vincristine.

CASE REPORT

Intrathecal vincristine was inadvertently injected into a twelve-year-old girl with acute lymphocytic leukemia. The error was immediately recognized and treated with cerebrospinalfluid drainage and cerebrospinal fluid exchange. Clinical evolution during the 83 days until death is described Multiple samples of cerebrospinal fluid were assayed for vincristine sulfate. Neuropathological post-mortem changes in the brain and spinal cord are reported

CONCLUSION

We compare our case with other previously reported cases in which patient survival was achieved with the same treatment. We summarize preventive measures to avoid such unfortunate occurrences.

Effects of an inadvertent dose of cytarabine in a child with Fanconi's anemia: reducing medication errors

We report the case of a 7-year-old boy with Fanconi's anemia, who underwent a bone marrow transplant using an unrelated donor, and who received an inadvertent dose of cytarabine (cytosine arabinoside). The cytarabine was given by mistake 6 months following transplant. This caused excessive toxicity to many systems, including the pulmonary and renal systems. The patient recovered from the episode, but this article further highlights the acute adverse effects of cytarabine. Furthermore, it is the first report of excessive toxicity to cytarabine in a child with Fanconi's anemia. The article also highlights the problems of medication administration errors, particularly in those exquisitely sensitive to the effects of toxic drugs.

Intrathecal chemotherapy with antineoplastic agents in children

Intrathecal chemotherapy with antineoplastic agents is mainly utilised in children with leukaemia and lymphoma, and in selected brain tumours. In these diseases, intrathecal use is restricted to methotrexate (MTX), cytosine arabinoside (Ara-C) and corticosteroids. A number of other agents are, at the present time, under evaluation. Intrathecal MTX administered sequentially with systemic high dose MTX infusion prolongs therapeutic cerebral spinal fluid (CSF) levels of the drug. Prolonged therapeutic CSF levels can also be achieved by giving repeated small intrathecal doses of MTX over an extended period in selected patients, with an implanted Ommaya reservoir. In the CSF, the metabolic inactivation of Ara-C is significantly lower than in plasma with a CSF clearance similar to the rate of CSF bulk flow. A slow-release formulation of Ara-C may be given intrathecally, resulting in a prolonged cytotoxic concentration in the CSF. CNS relapse and neurotoxicity in patients with acute lymphoblastic leukaemia, especially younger children, may be reduced by using age-related dosing of intrathecal MTX and Ara-C. Hydrocortisone is used in combination with MTX and Ara-C for so-called 'triple intrathecal chemotherapy' in the treatment of meningeal leukaemia. Intrathecal thiotepa does not appear to be advantageous over systemic administration in patients with brain and meningeal leukaemia. Monoclonal antibodies, reactive with tumour-associated antigens, can be used as delivery systems for chemotherapeutic agents and radionuclides. However, the development of this new approach is currently under evaluation in larger clinical studies. Neurological adverse effects may be expected with intrathecal chemotherapy and are increased by high dose systemic therapy, concomitant cranial radiotherapy or meningeal infiltration by neoplastic cells. Inadvertant intrathecal administration of antineoplastic agents that are indicated for systemic administration only, is dangerous and may result in a fatal outcome.

Variation in administration of cyclophosphamide and mesna in the treatment of childhood malignancies

The objective of this study was to describe the variation in preparation and administration of cyclophosphamide, mesna, and hydration for the treatment of childhood malignancies within clinical trial protocol documents. All cyclophosphamide-containing cooperative group (Pediatric Oncology Group) protocols that were open at Dana-Farber Cancer Institute in April 1998 were evaluated. Among the 14 active protocols, there were 23 unique cyclophosphamide regimens. Marked variation existed in infusion rate, fluid type, and volume used for admixing cyclophosphamide and mesna, as defined in the "Treatment" section of the protocols that we evaluated. Further variation was found in the type, amount, and rate of infusion of prehydration and posthydration fluid. Internal inconsistency existed within the protocols pertaining to the administration methods described in the "Agent Information," "Treatment," and "Consent" sections of the written documents. Clinical trial protocol documents serve as reference material for health care providers who prescribe, dispense, and administer protocol chemotherapy. Misinterpretation of protocol documents and clinician orders are contributing factors in serious and deadly medication errors. Internal inconsistency within protocol documents and variation in drug administration across protocols is a potential source of error. We recommend improved accuracy, clarity, and internal consistency of protocol documents to improve patient safety and compliance with protocol specifications. In addition, the use of standard concentrations, volumes, and methods of administration of chemotherapeutic agents and accompanying fluids is recommended.

Accidental iatrogenic intoxications by cytotoxic drugs: error analysis and practical preventive strategies

OBJECTIVES

Drug errors are quite common. Many of them become harmful only if they remain undetected, ultimately resulting in injury to the patient. Errors with cytotoxic drugs are especially dangerous because of the highly toxic potential of the drugs involved. For medico-legal reasons, only 1 case of accidental iatrogenic intoxication by cytotoxic drugs tends to be investigated at a time, because the focus is placed on individual responsibility rather than on system errors. The aim of our study was to investigate whether accidental iatrogenic intoxications by cytotoxic drugs are faults of either the individual or the system. The statistical analysis of distribution and quality of such errors, and the in-depth analysis of contributing factors delivered a rational basis for the development of practical preventive strategies.

METHODS

A total of 134 cases of accidental iatrogenic intoxication by a cytotoxic drug (from literature reports since 1966 identified by an electronic literature survey, as well as our own unpublished cases) underwent a systematic error analysis based on a 2-dimensional model of error generation. Incidents were classified by error characteristics and point in time of occurrence, and their distribution was statistically evaluated. The theories of error research, informatics, sensory physiology, cognitive psychology, occupational medicine and management have helped to classify and depict potential sources of error as well as reveal clues for error prevention.

RESULTS

Monocausal errors were the exception. In the majority of cases, a confluence of unfavourable circumstances either brought about the error, or prevented its timely interception. Most cases with a fatal outcome involved erroneous drug administration. Object-inherent factors were the predominant causes. A lack of expert as well as general knowledge was a contributing element. In error detection and prevention of error sequelae, supervision and back-checking are essential. Improvement of both the individual training and work environment, enhanced object identification by manufacturers and hospitals, increased redundancy, proper usage of technical aids, and restructuring of systems are the hallmarks for error prevention.

CONCLUSIONS

Errors follow general patterns even in oncology. Complex interdependencies of contributing factors are the rule. Thus, system changes of the working environment are most promising with regard to error prevention. Effective error control involves adapting a set of basic principles to the specific work environment. The work environment should allow for rectification of errors without penalty. Regular and ongoing intra-organisational error analysis needs to be an integral part of any error prevention strategy. However, it seems impossible to totally eliminate errors. Instead, if the environment guarantees timely error interception, most sequelae are avoided, and errors transform into a system-wide learning tool.

Pediatric case of accidental oral overdose of methotrexate

Methotrexate is a chemotherapy antimetabolite, folic acid antagonist, that inhibits the enzyme dihydrofolate reductase resulting in decreased levels of tetrahydrofolate in the cells. This in turn blocks synthesis of thymidylate, a nucleotide necessary for DNA synthesis. It is readily absorbed from the gastrointestinal tract. Toxicity from overdose can affect multiple organ systems including bone marrow, liver, intestinal tract, kidneys, lungs, skin, and blood vessels, resulting in death in severe cases. Methotrexate is widely used to treat neoplastic disease, dermatologic disorders (psoriasis), and rheumatologic disorders (severe rheumatoid arthritis). As its indications for use increase, more accidental overdoses can be expected. We present the treatment and clinical course of one such case, that of a 2-year-old who accidentally took her grandmother's arthritis pills. Her initial serum level was 10 times greater than that needed to cause toxicity. She was treated with gastric lavage, activated charcoal, leucovorin rescue, and ICU admission. Her clinical course was unremarkable, and the only evidence of toxicity was a mild elevation in a liver-associated enzyme that resolved without any clinical sequela. Leucovorin at a dose equal to or greater than the possible ingestion should be given as soon as possible in methotrexate overdoses.

DNA-analysis is mandatory in case of an uncommon malignancy

In a child a diagnosis of sweat gland carcinoma was made on basis of a surgical specimen presumed to be taken from an occipital lymph node. DNA analysis confirmed mixing of specimens in the referring hospital.

Accidental intramuscular vincristine: lack of untoward effects and recommendations for management

Vincristine was inadvertently injected into a thigh of three children. In each case the accident occurred as a result of the mixing of a syringe containing vincristine with a syringe of L-asparaginase which the patient was scheduled to receive on the same day. Within minutes, each patient was treated topically with cold compresses and the area was infiltrated with a solution of 8.4% sodium bicarbonate. Only one patient had discomfort of the thigh after the injection, none of the patients have had any sequelae, either acute or delayed. Measures to avoid mistaken injection of vincristine for asparaginase are readily achievable and have prevented recurrences of intramuscular vincristine administration at the institutions where they have been implemented. Nonetheless, other instances of intramuscular vincristine injection are anticipated and should be rapidly recognized and quickly managed with local applications of cold and sodium bicarbonate.