A continuous-improvement approach for reducing the number of chemotherapy-related medication errors

A comprehensive, interdisciplinary approach for reducing the number of chem otherapy-related medication errors at the National institutes of Health Cli nical Center, where approximately 8500 doses of chemotherapy agents are dis pensed annually, is described. Heightened awareness of the seriousness of chemotherapy-related medication errors prompted formation of an interdisciplinary task force in June 1995 t o analyze and improve the hospital's system for ordering, checking, process ing, and administering cancer chemotherapy agents. Problems were analyzed a nd rectified in accordance with the hospital's plan-do-check-act performanc e-improvement model. Performance monitors for the improvements included a s ystem to record and categorize all chemotherapy-related prescribing errors and a hospitalwide occurrence-reporting system. The task force identified s even major categories in which improvements were needed: protocol developme nt computer-system enhancements, dose verification, information access, edu cation for health care practitioners, error follow-up, and infusion pumps. Despite the Clinical Center's good safety-net system, 23 modifications were made to the existing system through December 1999. These changes resulted in an overall 23% decrease in prescribing errors and a 53% decrease in seri ous prescribing errors. The task force membership was recently broadened to include representatives of additional departments where chemotherapy agent s are used, and this group recommended more than 20 additional system chang es. The changes are being implemented, and their effect on reducing the num ber of chemotherapy-related errors will be measured. The continuous-improvement process used prospectively by the task force hel ps ensure that safe chemotherapy practices are instituted uniformly through out the hospital.