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.”