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Chemotherapy errors do reach children


According to a report published early online in Cancer, paediatric chemotherapy medication errors often reach the patients, exposing them to potential harm.

US researchers searched through all error reports (1999-2004) relating to paediatric chemotherapy preparations, recorded in the US Pharmacopeia (USP) MEDMARX database – a voluntary national internet-based error reporting system. The objectives were to identify patterns in paediatric chemotherapy errors, including the types of errors created, causes of errors, level of harm of errors, location of errors and characteristics of facilities associated with errors for children.

A total of 310 relevant error reports were identified; of these, 55.2% occurred in inpatient units, 10% occurred in outpatient settings, and 34.8% had unknown locations. Overall, 264 of the reported chemotherapy errors (85%) reached the patient, and 49 errors (15.6%) created the need for additional patient monitoring or therapeutic intervention.

The most common error node reported was administering (149 errors), followed by dispensing (94 errors). When examining the 171 inpatient errors versus the 31 outpatient errors, 42% of outpatient errors were administering errors, 32.3% were dispensing error, and 22.6% were prescribing errors, compared with 50%, 23.4% and 11.7%, respectively, for inpatient error reports.

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%). The most common medication classes involved in the error reports were antimetabolites (39.5%), alkylating agents (14.0%), anthracyclines (9.3%) and topoisomerase inhibitors (9.3%).

The authors note several limitations to their data, including the voluntary nature of the database, the fact that most errors were reported by nurses and pharmacists and the fact that some of the included medications are not used solely for oncology indications.

They conclude: “These data suggest clear areas for intensive patient safety research and development of targeted interventions to improve the safe delivery of paediatric chemotherapy medications. Paediatric hospitals and future quality improvement research should target medication administration safeguards for these high-risk medications and should consider different and specific solutions for inpatient and outpatient paediatric oncology units, respectively,”

Cancer early online publication, 25 May 2007


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