title: Drug administration error related to computerized prescribing.
abstract: BACKGROUND
  One of the main reasons for the implementation of computer-based prescribing was to reduce medication errors. However, the risk has not fallen to zero and new kinds of errors have been detected.
  
  
  METHODS
  the following case relates one of these medication errors involving a preparation of vincristine. This antineoplastic drug was injected to a patient via a subcutaneous route of administration instead of an intravenous bolus injection.
  
  
  RESULTS
  consequently, a cutaneous erythema appeared. This incident resulted from an error in the programming of the administration route of the protocol operated by a pharmacist and a physician. The pharmacist, who was responsible for the validation of the computerized medical order and then for the compounding and the dispensing of the drug, did not detect the error.
  
  
  CONCLUSIONS
  this case highlights the need of improved and irreproachable therapeutic protocols. Recorded in a database, they must be validated pharmaceutically and medicinally to secure computer-based prescribing, drug handling, dispensing, and administering of the antineoplastic drugs. Even if the pharmaceutical analysis of prescriptions is made easier with computerization, we encourage the training of nurses and the evaluation of their knowledge as well as the necessity for pharmacists to learn to detect new kinds of errors and to verify periodically protocols.
authors.affiliation: Hôpital d'instruction des armées du Val de Grâce, Pharmacy Department, Paris, France. le.garlantezec.pharm@gmail.com
authors.forename: P
authors.initials: P
authors.lastname: Le Garlantezec
authors.forename: O
authors.initials: O
authors.lastname: Aupée
authors.forename: D
authors.initials: D
authors.lastname: Alméras
authors.forename: L
authors.initials: L
authors.lastname: Lefeuvre
authors.forename: B
authors.initials: B
authors.lastname: Souleau
authors.forename: A
authors.initials: A
authors.lastname: Sgarioto
authors.forename: X
authors.initials: X
authors.lastname: Bohand
mesh_terms: D000972:Antineoplastic Agents, Phytogenic / Q000008:administration & dosage* / Q000009:adverse effects* / Q000627:therapeutic use; D055695:Electronic Prescribing; D004890:Erythema / Q000139:chemically induced; D005260:Female; D006689:Hodgkin Disease / Q000188:drug therapy; D006801:Humans; D007275:Injections, Intravenous; D007279:Injections, Subcutaneous / Q000009:adverse effects; D008508:Medication Errors; D008875:Middle Aged; D024382:Professional Role; D012984:Software; D016896:Treatment Outcome; D014750:Vincristine / Q000008:administration & dosage* / Q000009:adverse effects* / Q000627:therapeutic use
chemical_list: D000972:Antineoplastic Agents, Phytogenic; D014750:Vincristine