Infallible measures needed to prevent errors in the administration of chemotherapeutic agents

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.

Accidental busulfan overdose during conditioning for stem cell transplantation

High dose busulfan is widely used in preparative regimens for bone marrow transplantation. We describe three cases of accidental busulfan overdosing. Two adults received a single dose of 8 and 18 mg/kg busulfan, respectively. Doses of 9 x 4 mg/kg were ingested by a 14-year-old girl, who experienced seizures. In all cases, no severe liver toxicity including veno-occlusive disease was observed. Plasma samples were obtained from two patients. Busulfan plasma concentrations were far above published values after high-dose busulfan treatment. Busulfan was eliminated by a first-order process. All patients survived these high doses of busulfan and successful transplantation was possible. Two patients died from refractory GvHD on days 91 and 80 after transplantation. One patient is alive in remission after an observation time of 18 months. These cases show that busulfan overdosing may occur and pharmacokinetic evaluation is warranted to estimate risk of early and late toxicity.

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.

A closer look at chemotherapy errors

Lehigh Valley Hospital and Health Network, a 700-bed tertiary care system, created a reference guide as part of its chemotherapy error prevention initiative.