title: Characteristics of pediatric chemotherapy medication errors in a national error reporting database.
abstract: BACKGROUND
  Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors.
  
  
  METHODS
  The authors queried the United States Pharmacopeia MEDMARX database, a national, voluntary, Internet-accessible error reporting system, for all error reports from 1999 through 2004 that involved chemotherapy medications and patients aged <18 years.
  
  
  RESULTS
  Of the 310 pediatric chemotherapy error reports, 85% reached the patient, and 15.6% required additional patient monitoring or therapeutic intervention. Forty-eight percent of errors originated in the administering phase of medication delivery, and 30% originated in the drug-dispensing phase. Of the 387 medications cited, 39.5% were antimetabolites, 14.0% were alkylating agents, 9.3% were anthracyclines, and 9.3% were topoisomerase inhibitors. The most commonly involved chemotherapeutic agents were methotrexate (15.3%), cytarabine (12.1%), and etoposide (8.3%). The most common error types were improper dose/quantity (22.9% of 327 cited error types), wrong time (22.6%), omission error (14.1%), and wrong administration technique/wrong route (12.2%). The most common error causes were performance deficit (41.3% of 547 cited error causes), equipment and medication delivery devices (12.4%), communication (8.8%), knowledge deficit (6.8%), and written order errors (5.5%). Four of the 5 most serious errors occurred at community hospitals.
  
  
  CONCLUSIONS
  Pediatric chemotherapy errors often reached the patient, potentially were harmful, and differed in quality between outpatient and inpatient areas. This study indicated which chemotherapeutic agents most often were involved in errors and that administering errors were common. Investigation is needed regarding targeted medication administration safeguards for these high-risk medications.
authors.affiliation: Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Rinke
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Shore
authors.forename: Laura
authors.initials: L
authors.lastname: Morlock
authors.forename: Rodney W
authors.initials: RW
authors.lastname: Hicks
authors.forename: Marlene R
authors.initials: MR
authors.lastname: Miller
mesh_terms: D000293:Adolescent; D016907:Adverse Drug Reaction Reporting Systems / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D019992:Databases as Topic / Q000706:statistics & numerical data*; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008508:Medication Errors / Q000379:methods / Q000706:statistics & numerical data*; D004364:Pharmaceutical Preparations / Q000008:administration & dosage; D010602:Pharmacopoeias as Topic; D014481:United States
chemical_list: D004364:Pharmaceutical Preparations