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5PSQ-117 Analysis of medication errors in an oncology setting using an internal reporting system
  1. SAM Urru1,
  2. A Campomori1,
  3. P Serra2,
  4. GA Carrucciu2,
  5. A Pasqualini1,
  6. SG Gheza2,
  7. G Temporin1,
  8. V Garau2
  1. 1S Chiara Hospital, Hospital Pharmacy, Trento, Italy
  2. 2‘A Businco’ Oncology Hospital, Hospital Pharmacy, Cagliari, Italy


Background and importance The last 20 years have seen a growing awareness of the effect of human error in healthcare in oncology practice. Despite global advances in healthcare practices, an estimated 1 in 10 patients is still harmed while receiving care. In 2017, the World Health Organization published ‘Medication without harm, global patient safety challenge’, calling for action to reduce patient harm due to unsafe medication practices and medication errors. The Italian Ministry of Health issued the ‘Raccomandazione 14’ to provide the Italian health system with shared unequivocal procedures for anticancer drug supply, compounding, storage, prescription and administration. Although some progress has been made, error measurement methods and prevention strategies remain important areas of research.

Aim and objectives Our main aim was to evaluate the effectiveness of the pharmacy occurrence–reporting system and to study which procedures can be put in place to minimise drug preparation errors in oncology.

Material and methods In two oncology settings, the effectiveness of the pharmacy occurrence–reporting system was determined over a period of a year and a half to increase occurrence reporting within the pharmacy and allow administrators to identify specific areas for improvement within the chemotherapy drug preparation process. These events were identified according to the number and type of near misses documented by pharmacy staff. A web based error reporting form was developed for all steps of the pharmacy preparation process. The pharmacy staff was asked to complete the form when a new error occurred.

Results During the evaluation period, eight errors were reported to the hospital’s error reporting system. In contrast, 401 total pharmacy events were documented using the pharmacy’s internal occurrence–reporting system: 46.6% were classified as errors, 25.2% as non-conformity errors, 23.2% as near miss errors and 5.0% of the reported events involved high alert medications according to the institution’s high alert medications policy classified as sentinel events.

Conclusion and relevance A pharmacy internal occurrence–reporting system increased staff reporting and identified areas for improvement within the medication distribution process that may not have been recorded by a hospital based reporting system. Oncology preparation therapy must be regarded as a high risk activity and improvement in risk management procedures to minimise risk to patients has to be seen as a priority of the pharmacist’s work.

References and/or acknowledgements No conflict of interest.

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