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PS-106 Administration mistakes in cytostatic unit
  1. M Moya-Martin,
  2. M Vázquez-Real,
  3. MD Alvarado Fernández,
  4. MC Donoso Rengifo,
  5. L Jiménez Guerrero,
  6. S Santana
  1. Hospital Universitario Virgen Macarena, Pharmacy, Seville, Spain

Abstract

Background The cytostatic unit is a critical area in a hospital, therefore drug-related mistakes should be analysed in order to increase safety and effectiveness in patients treated with chemotherapy.

Purpose To evaluate drug-related mistakes during transcription, preparation or administration of cytostatics.

Material and methods Prospective study, two months duration, in which every member of staff involved in the validation (pharmacists), preparation for compounding, compounding and administration of cytostatics (nurses) reported any mistake found, including category of mistake, date and who detected it.

Results 73 drug-related mistakes were recorded at the cytostatic unit: prescription mistakes (28.3%), transcription mistakes (39.3%), compounding mistakes (16.6%), pre-compounding mistakes (15.8%).

Of them, 60.3% were category A, 25.1% category B, 5.1% category C and 9.5% category D. Category A was defined as circumstances or incidents able to end in a mistake, B, there was a mistake but it did not reach the patient, C, the mistake reached the patient but it did not cause any damage, and D, although it caused no damage, monitoring and/or intervention was needed.

A total of 20.6% mistakes were reported by the pharmacist, 30% by nurses in charge of compounding, 32.1% by nurses in charge of preparation, 5.8% by staff nurses, and 11.5% by nurses in charge of administration.

Conclusion It is vital to ensure a system of safe validation and be sure to avoid any mistakes that could reach the patient in the case of chemotherapy. Cytostatics have a narrow therapeutic range, so therefore minimal mistakes could end in fatal consequences.

References and/or acknowledgements Cytostatic unit of a tertiary hospital.

No conflict of interest.

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