Medication errors involving oral chemotherapy.
BACKGROUND
Given the expanding use of oral chemotherapies, the authors set out to examine errors in the prescribing, dispensing, administration, and monitoring of these drugs.


METHODS
Reports were collected of oral chemotherapy-associated medication errors from a medical literature and Internet search and review of reports to the Medication Errors Reporting Program and MEDMARX. The authors solicited incident reports from 14 comprehensive cancer centers, and also collected incident reports, pharmacy interventions, and prompted clinician reports from their own center. They classified the type of incident, severity, stage in the medication use process, and type of medication error. They examined the yield of the various reporting methods to identify oral chemotherapy-related medication errors.


RESULTS
The authors identified 99 adverse drug events, 322 near misses, and 87 medical errors with low risk of harm. Of the 99 adverse drug events, 20 were serious or life-threatening, 52 were significant, and 25 were minor. The most common medication errors involved wrong dose (38.8%), wrong drug (13.6%), wrong number of days supplied (11.0%), and missed dose (10.0%). The majority of errors resulted in a near miss; however, 39.3% of reports involving the wrong number of days supplied resulted in adverse drug events. Incidents derived from the literature search and hospital incident reporting system included a larger percentage of adverse drug events (73.1% and 58.8%, respectively) compared with other sources.


CONCLUSIONS
Ensuring oral chemotherapy safety requires improvements in the way these drugs are ordered, dispensed, administered, and monitored.
Center for Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA. saul_weingart@dfci.harvard.edu
Saul N
SN
Weingart
Julio
J
Toro
Justin
J
Spencer
Deborah
D
Duncombe
Anne
A
Gross
Sylvia
S
Bartel
Jeremy
J
Miransky
Ann
A
Partridge
Lawrence N
LN
Shulman
Maureen
M
Connor
D000284:Administration, Oral; D016907:Adverse Drug Reaction Reporting Systems; D000970:Antineoplastic Agents / Q000008:administration & dosage*; D016903:Drug Monitoring; D064420:Drug-Related Side Effects and Adverse Reactions; D006801:Humans; D015994:Incidence; D008508:Medication Errors / Q000706:statistics & numerical data*; D055656:Prescriptions
D000970:Antineoplastic Agents