Typical medication errors in oncology: Analysis and prevention strategies

Onkologie

Volumn 26, Issue 6, 2003, Pages 539-544

  Muller T ^a  

^a Dietrich Bonhoeffer Klinikum   (Germany)

Author keywords

Antineoplastic agents; Chemotherapy; Error prevention strategies; Medication errors

Indexed keywords

ADRENALIN; ADRENERGIC RECEPTOR STIMULATING AGENT; AMPHOTERICIN; ANALGESIC AGENT; ANTHRACYCLINE DERIVATIVE; ANTIHISTAMINIC AGENT; ANTIINFECTIVE AGENT; ANTINEOPLASTIC AGENT; BLOOD DERIVATIVE; CACLYX; CARBOPLATIN; CARDIOVASCULAR AGENT; CISAPRIDE; CISPLATIN; DAUNORUBICIN; DIAGNOSTIC AGENT; DIATRIZOATE; DIPALMITOYLPHOSPHATIDYLCHOLINE; DOXORUBICIN; EPIRUBICIN; ESMOLOL; FLUCONAZOLE; GASTROINTESTINAL AGENT; HEPARIN; HORMONE; IDARUBICIN; INSULIN; LIDOCAINE; NEOCARBO; OPIATE; OXALIPLATIN; PARACETAMOL; PLATINUM DERIVATIVE; POTASSIUM CHLORIDE; PSYCHOTROPIC AGENT; RIBOCARBO; UNINDEXED DRUG; VINCRISTINE; WARFARIN;

CANCER CHEMOTHERAPY; CARDIOTOXICITY; COMPUTER PROGRAM; DOSE CALCULATION; DRUG FORMULATION; DRUG INFUSION; HUMAN; INFUSION PUMP; INTOXICATION; LUNG TOXICITY; MEDICATION ERROR; NEPHROTOXICITY; NEUROTOXICITY; ONCOLOGY; REVIEW; TREATMENT PLANNING;

ANTINEOPLASTIC AGENTS; ANTINEOPLASTIC COMBINED CHEMOTHERAPY PROTOCOLS; DRUG INTERACTIONS; DRUG THERAPY, COMPUTER-ASSISTED; HUMANS; INFUSION PUMPS; INJECTIONS, SPINAL; MEDICATION ERRORS; NEOPLASMS; OVERDOSE;

EID: 0346350326     PISSN: 0378584X     EISSN: None     Source Type: Journal    
DOI: 10.1159/000074148     Document Type: Review

References (39)

1. Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY, Pamer C: Retrospective analysis of mortalities associated with medication errors. Am J Health-Syst Pharm 2001;58:1835-1841.
2. Chen CS, Seidel K, Armitage JO, Fay JW, Appelbaum FR, Horowitz MM, Shpall EJ, Weiden PL, Antman KS, Champlin RE, Kersey JH, Sullivan KM: Safeguarding the administration of high-dose chemotherapy: A national practice survey by the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 1997;3:331-340.
3. Brennan TA, Leape LL, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt HH: The nature of adverse events in hospitalized patients. Results of the Harvard medical practice study II. N Engl J Med 1991;324:377-384.
4. Ebbesen J, Buajourdet I, Erikssen J, Brors O, Hilberg T, Svaar H, Sandvik L: Drug-related deaths in a department of internal medicine. Arch Intern Med 2001;161:2317-2323.
5. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA: Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-2120.
6. Lazarou J, Pomeranz BH, Corey PN: Incidence of adverse drug reactions in hospitalized patients: A meta-analysis of prospective studies. JAMA 1998;279:1200-1205.
7. Ross LM, Wallace J, Paton JY: Medication errors in a pediatric teaching hospital in the UK: Five years operational experience. Arch Dis Child 2000;83:492-497.
8. Schnurrer JU, Frölich JC: Zur Häufigkeit und Vermeidbarkeit von tödlichen unerwünschten Arzneimittelwirkungen. Internist 2003;44:889-895.
9. Taxis K, Barber N: Ethnographic study of incidence and severity of intravenous drug errors. BMJ 2003;326:684-687.
10. Kohn LT, Corrigan JM, Donaldson MS (ed): To err is human: Building a safer health system. Washington, National Academy Press, 2000.
11. Crane M: Who caused this tragic medication mistake? Medical Economics 2001;19:49.
12. Paul C: Back form the brink: Making chemotherapy safer. Dana-Farber Cancer Institute, Boston; in Findley S (ed): Reducing Medical Errors and Improving Patient Safety. Washington DC, National Coalition on Health Care, 2000.
13. U.S. Food and Drug Administration News: FDA proposes drug bar code regulation. March 13, 2003.
14. Erdlenbruch B, Lakomek M, Bjerre LM: Chemotherapy errors in oncology. Med Pediatr Oncol 2002;38:353-356.
15. Müller T: Kunstfehler in der Arzneimitteltherapie. Arzneimitteltherapie 2003;21:48-54.
16. Ollenschläger G: Medizinische Risiken, Fehler und Patientensicherheit: Zur Situation in Deutschland. Schweiz Ärztez 2001;82:1404-1410.
17. Ahlke E, Barth J, Freidank A, Lipp HP, Nikitsch, Stützle M: Zytostatika - Wirkstoffe mit geringer therapeutischer Breite. Dtsch Apoth Z 2000;140:3712-3716.
18. France DJ, Miles P, Cartwright J, Patel N, Ford C, Edens C, Whitlock JA: A chemotherapy incident reporting and improvement system (CIRIS). Jt Comm J Qual Saf 2003;29:171-180.
19. Schulmeister L: Chemotherapy medication errors: Description, severity, and contribution factors. Oncol Nurs Forum 1999;26:1033-1042.
20. Dettmeyer R, Driever F, Becker A, Wiestler OD, Madea B: Fatal myeloencephalopathy due to accidental intrathecal vincristin administration: A report of two cases. Forensic Sci Int 2001;122:60-64.
21. Inquiry into cancer drug tragedy. BBC News, 24.01.2001.
22. Jardine LF, Ingram LC, Bleyer WA: Intrathecal leucovorin after intrathecal methotrexate overdose. J Pediatr Hematol Oncol 1996;18:302-304.
23. Lee AC, Wong KW, Fong KW, So KT: Intrathecal methotrexate overdose. Acta Paediatr 1997;86:434-437.
24. Riva L, Conter V, Rizzari C, Jankovic M, Sala A, Milani M: Successful treatment of intrathecal methotrexate overdose with folinic acid rescue: A case report. Acta Paediatr 1999;88:780-782.
25. Spritze mit ẗdlichen Folgen. Kieler Nachrichten, 07.04.2001.
26. Woods K: The prevention of intrathecal medication errors. London, Department of Health, 2001.
27. Choi JH, Oh JC, Kim KH, Chong SY, Kang MS, Oh do Y: Successful treatment of cisplatin overdose with plasma exchange. Yonsei Med J 2002;43:128-132.
28. Chu G, Mantin R, Shen YM, Baskett G, Sussman H: Massive cisplatin overdose by accidental substitution for carboplatin. Toxicity and management. Cancer 1993;72:3707-3714.
29. Erdlenbruch B, Pekrun A, Schiffmann H, Witt O, Lakomek M: Accidental cisplatin overdose in a child: Reversal of acute renal failure with sodium thiosulfate. Med Pediatr Oncol 2002;38:349-352.
30. Ukens C: Lawsuit alleges fatal chemo drug error by community pharmacist. Drug Topics 2001;1:10.
31. Bates DW, Gawande AA: Improving safety with information technology. N Engl J Med 2003;348:2526-2534.
32. Bates DW: Using information technology to reduce rates of medication errors in hospitals. BMJ 2000;320:788-791.
33. Nightingale PG, Adu D, Richards NT, Peters M: Implementation of rules based computerised bedside prescribing and administration: Intervention study. BMJ 2000;320:750-753.
34. Knaup P, Wiedemann T, Bachert A, Creutzig U, Haux R, Schilling F: Efficiency and safety of chemotherapy plans for children: CATIPO - nationwide approach. Artif Intell Med 2002;24:229-242.
35. Goldspiel BR, DeChristoforo R, Daniels CE: A continuous-improvement approach for reducing the number of chemotherapy-related medication errors. Am J Health-Syst Pharm 2000;57:S4-S9.
36. Ferner RE, Aronson JK: Errors in prescribing, preparing, and giving medicines - definitions, classifications, and prevention; in Aronson JK (ed): Side Effects of Drugs, annual 22. Amsterdam, Elsevier, 1999: pp 22-36.
37. Fortescue EB, Kaushal R, Landrigan CP, KcKenna KJ, Clapp MD, Federico F, Goldmann DA, Bates DW: Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003;111:722-729.
38. Sexton JB, Thomas EJ, Helmreich RL: Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. BMJ 2000;320:745-749.
39. Nolan TW: System changes to improve patient safety. BMJ 2000;320:771-778.