Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy.
OBJECTIVE
To analyze medication errors (MEs) in a multidisciplinary system with a Computerized Pharmacotherapy Process (CPP) in cancer patients.


METHODS
A longitudinal, prospective 2-year (January 2003 -to December 2004) cohort study was made in adult patients administered antineoplastic treatment in Services of Oncology and Haematology. MEs were identified by double cross-validation of each stage of the pharmacotherapeutic process (prescription, preparation, dispensing, administration, and follow-up) carried out by the multidisciplinary team (physician, pharmacist, nurse) with CPP assistance.


METHODS
Number of MEs per 1000 patient-days, percentage according to the stage of the pharmacotherapeutic process and the severity of intercepted ME (scored from 1 = no damage to the patient, to 5 = patient death).


RESULTS
A total of 1311 patients were receiving treatment, and MEs were identified in 225. Out of a total of 13,158 patient-days, 276 MEs were detected, equivalent to 20.9 MEs per 1000 patient-days; of these, 16.8 MEs per 1000 patient-days (80%) were intercepted and did not affect any patient. The detected ME distribution according to pharmacotherapeutic stage was: prescription 75.7%, preparation 21.0%, dispensing 1.8%, administration 1.1%, and follow-up 0.4%. ME distribution according to severity was: grade 1 : 15.9%, grade 2 : 49.6%, grade 3 : 33.7%, grade 4 : 0.7%, and grade 5 : 0%. The system intercepted 98.9% of all MEs with severity >or=3 (MEs with a potential for causing patient damage).


CONCLUSIONS
The multidisciplinary system with a well-established CPP detects 20.9 MEs per 1000 patient-days and intercepts 98.8% of all MEs with a potential for causing patient damage.
Serrano-Fabiá
Amparo
A
Pharmacy Deparment, Hospital Manacor, Baleares, Spain. serrano_ampfab@gva.es
Albert-Marí
Asunción
A
Almenar-Cubells
Daniel
D
Jiménez-Torres
N Víctor
NV
D000970:Antineoplastic Agents / Q000009:adverse effects*; D015331:Cohort Studies; D005500:Follow-Up Studies; D006785:Hospitals, University / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007400:Interprofessional Relations; D008137:Longitudinal Studies; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D009726:Nurses / Q000592:standards; D010595:Pharmacists / Q000592:standards; D010820:Physicians / Q000592:standards; D011446:Prospective Studies
D000970:Antineoplastic Agents