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GRP-018 Analysis of Antineoplastic Medication Errors in a 500-Bed Teaching Hospital
  1. R Gavira Moreno,
  2. MT Moreno Carvajal,
  3. V González Rosa,
  4. F Gómez de Rueda,
  5. R Gázquez Pérez,
  6. JP Díaz López,
  7. P Gómez Germá,
  8. MA Almendral Vicente,
  9. MT Gómez de Travecedo y Calvo,
  10. M Lobato Ballesteros
  1. Hospital del SAS de Jerez, Farmacia, Jerez de la Frontera (Cádiz), Spain

Abstract

Background Medication errors with antineoplastic drugs may be catastrophic due to the drugs’ high toxicity and narrow therapeutic index.

Purpose To assess antineoplastic medication errors in terms of frequency, type of error and severity for patients.

Materials and Methods A 1-year prospective study was conducted (2011) in order to identify the medication errors that occurred during cancer chemotherapy for patients in a 500-bed teaching hospital. Wards included both day care and inpatient units. All prescriptions and production forms were verified by pharmacists. The different types of error were defined in a data collection form. For each medication error intercepted, the potential severity was evaluated according to the Ruiz-Jarabo 2000 version2 classification system.

Results During the study period, the pharmacy unit prepared 17241 distinct anticancer drugs. In total, 136 medications errors were detected throughout the medicines use process. Prescriptions errors represented 82% of errors, followed by pharmaceutical validation (7%) transcription (7%), preparation (2%) and administration errors (2%).

The most common causal drug was carboplatin, which was involved in 25 cases, despite corresponding to only 2.8% of anticancer drugs prescribed at our institution. Overall, in 66 cases erroneous doses of the medicine were recorded (48.5%), 24 errors were linked to the choice of antineoplastic regimen (17.6%) while in 12 cases, erroneous duration of treatment was prescribed (8.8%).

Of the 136 medication errors, 124 were intercepted prior to administration while 12 reached the patients (9%). Overall 66% of non-intercepted medication errors had no impact on the patient and only 3 cases required enhanced monitoring.

Conclusions In our study pharmaceutical validation mainly allowed us to identify prescription errors (82%), almost all errors were intercepted prior to administration to the patient. Wrong dose represented the most common type of error. Few pharmaceutical errors (transcription, validation, preparation) were detected.

No conflict of interest.

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