Pharmacy Practice News – Preventing Oral Chemo Errors: A Team Approach

Source: www.pharmacypracticenews.com

“In recent years, oral antineoplastic agents have transformed the care of cancer patients. They have also brought new challenges, particularly in the case of medication errors.
Table 1. Common Causes of Cancer Chemotherapy ErrorsMiscommunicated verbal ordersExcessive interruptions during order processingLack of patient information, such as past medications, lab data and demographicsPoor packaging/labelingConfusion because of similar- sounding drug names or the use of abbreviationsLegibility issues due to handwriting or a poor copy/faxMisunderstanding total course dose given every dayFailure to round a doseMiscalculation in the ordering or dispensing processDrug shortages, which lead to drug concentration changes or the use of alternative agents

Oral cancer drugs are “some of the most toxic [compounds] on the market,” and when errors occur, they can be especially dangerous, noted Raymond Muller, MS, RPh, the associate director, Division of Pharmacy Services, Memorial Sloan-Kettering Cancer Center (MSKCC), New York City. Mr. Muller discussed strategies for reducing these errors during a recent webinar sponsored by the Institute for Safe Medication Practices (ISMP).

Chemotherapy mishaps have multiple causes, Mr. Muller noted, including poor packaging/labeling, interruptions during order processing or a misunderstanding of a drug regimen’s total daily dose. A 2010 study identified 508 oral antineoplastic errors through MEDMARX and other databases (Cancer 2010;116:2455-2464). The most common reason for error was wrong dose (38.8%), followed by wrong drug (13.6%), wrong number of days supplied (11.0%) and missed doses (10%). Roughly one-third of the mishaps were due to pharmacy dispensing errors. “That is significantly higher than most medication safety studies,” Mr. Muller said. “Usually, if you look at [the literature], dispensing errors are typically responsible for about 15% of events.”

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