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GRP-158 Reporting and Analysis of Errors in Cancer Treatment in the Antiblastic Drugs Laboratory of the European Institute of Oncology
  1. M Milani,
  2. V Sirna,
  3. I Cò,
  4. E Omodeo Salè
  1. European Institute of Oncology, Pharmacy, Milan, Italy

Abstract

Background The lack of management software for patients undergoing chemotherapy suggested to us that we should investigate errors that have occurred at all stages of the process: prescription, transcription, preparation, distribution and administration of treatment.

Purpose To encourage reports and classify the errors, in order to develop a computerised system of internal management of chemotherapy which can reduce the risk of error at all stages.

Materials and Methods Two reporting channels were established: one for major errors, such as prescriptions or preparations containing incorrect drugs or dosages, improper units of measurement, diluents incompatible with the active ingredient, improper administration. These errors are shared in corporate software with the Risk Management Office.

The second concerns minor errors, prescriptions containing compilation errors, incomplete compilation of the treatment regimen, incomplete administration of treatment; these errors are reported in an internal Excel file.

Results From January to September 2012, 73 major errors were reported from a total of 30406 preparations. Some of these were: prescription of paclitaxel instead of docetaxel, vinorelbine written as vinblastine; preparation of a 5-fluorouracil weekly dose in a two-day infusor, administration of paclitaxel bag to the wrong patient. In 85% of these cases the intervention of pharmacist avoided the error. 468 minor errors were reported, including 447 prescription errors, 3 transcription errors, 8 for lack of a cheque of the output treatment and 10 for incomplete delivery of the treatment.

Conclusions This analysis allowed us to draw a picture of the most frequent types of error. Most of them concerned the prescription stage, which we hope to minimise with the implementation of a computerised prescribing system. This will also cut down the transcription and administration errors by reading the barcode of the preparation with a patient wristband. The reduced number of preparation errors can be attributed to the use of an automated system for chemotherapy preparation.

No conflict of interest.

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