A review of the national chemotherapy errors database and recommendations for safe administration

Medication errors are not uncommon. Cancer chemotherapy errors are particul arly prone to result in serious and fatal complications. We report here on the most common causes for chemotherapy errors and suggest guidelines to pr event these errors. Review of literature on cancer chemotherapy errors show s that approximately 2% of orders contain errors; errors are costly; and oc cur especially during transfer in or out of oncology units (e.g. intensive care units). Predisposing factors for errors are fatigue of staff, insuffic ient training and/or supervision of staff, lack of pharmacist involvement i n writing or verifying orders, inadequate on-site protocol resources to ver ify details, and adverse environmental conditions. Review of data from the U.S. Pharmacopeia Medication Errors Reporting Program relating to 38 report s on 40 patients is reviewed. Of these, 28 patients received the wrong drug or dose. Consequences were none in 5, renal failure in 3, neutropenia in 1 , pain in 1, paralysis in 1, quadriplegia in i, paralytic ileus in i, heari ng loss in i, and drowsiness in 1. Twenty one percent of patients who recei ved incorrect medications or doses died. Five involved cis- or carbo-platin um, and one vincristine. The causes for errors in 22 of the 28 cases relate d to names of drugs which looked and/or sounded alike. In seven cases the t otal amount of drug to be given over entire time course was given in a sing le day, this error had the greatest potential for serious complication and death. In three cases, typing errors in protocol, article or books were res ponsible. We recommend the following guidelines: careful checks of weights and heights reported by at least two separate individuals; calculation of a ctual and ideal body surface areas and use of that which is less; restricti on of ordering to dedicated staff in oncology units; pharmacist and attendi ng physician review and signature on all orders; and preprinted order forms according to protocols. We also recommend use of full generic names, prohi bit trailing zeros but allow leading zeros in doses (i.e. 1.0, not 1.00; 0. 1 not .1). Daily doses only are required, and never dose of entire course o f chemotherapy These and other guidelines can help to prevent serious and f atal complications in an oncology or bone marrow transplant unit.