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PS-010 Screening of electronically prescribed cytostatic drug protocols for medication errors
  1. M Fortuna,
  2. T Hazdovac,
  3. M Sonc,
  4. P Tavcar,
  5. I Virant,
  6. M Kovacevic,
  7. S Rozman,
  8. A Eberl
  1. Institute of Oncology, Pharmacy, Ljubljana, Slovenia


Background The Institute of Oncology in Ljubljana is the leading institution for cancer care in the country and has a busy pharmacy department. The prescription and preparation of cytostatic drugs must be closely monitored, since they are highly toxic and pose a serious health hazard if errors occur in prescriptions for medicines. Pharmacists with knowledge of chemotherapy protocols are thus a key factor in improving the standard of patient care, as they can spot specific errors on chemotherapy prescriptions.

Purpose To analyse the number of pharmacists’ interventions over a one year period and evaluate their impact on safety and effectiveness of patient care.

Material and methods A review of all pharmacists’ interventions from August 2013 to July 2014 has been carried out. All errors detected were then evaluated by the team of pharmacists and sorted according to their potential to cause harm. Measures to eliminate such mistakes in the future have also been proposed. The interventions were communicated by phone to ensure that the right treatment had been selected and the correct medicines validated in the computer program Cypro.

Results The total number of prescriptions was 22,120 and the pharmacy dispensed 48,442 cytostatic preparations. The errors causing most concern were: wrong treatment protocol selected, different patient selected (two patients with the same or similar name), omitted validation for 1 or more drugs from the treatment protocol and erroneous dose orders due to a variety of input mistakes (wrong weight or height, body surface area and random bias).

Conclusion Medicines errors should not occur when using approved protocols from the computer program (Cypro). Nevertheless, pharmacist supervision is still needed, since medicines prescription errors happen despite the existence of inputted schemes, as was shown in our study. Only experienced pharmacists with expertise in chemotherapy drugs and pharmacology of cytostatic drugs can identify errors, communicate with physicians and validate the correct treatment orders.

References and/or acknowledgements No conflict of interest.

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