Characteristics of pediatric chemotherapy medication errors in a national error reporting database

Michael L. Rinke, Andrew D. Shore, Laura Morlock, Rodney W. Hicks, Marlene R. Miller

Research output: Contribution to journalArticle

63 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)186-195
Number of pages10
JournalCancer
Volume110
Issue number1
DOIs
StatePublished - Jul 1 2007
Externally publishedYes

Fingerprint

Medication Errors
Databases
Pediatrics
Drug Therapy
Topoisomerase Inhibitors
Antimetabolites
Equipment and Supplies
Pharmacopoeias
Alkylating Agents
Anthracyclines
Cytarabine
Community Hospital
Physiologic Monitoring
Etoposide
Methotrexate
Internet
Inpatients
Outpatients
Communication
Pharmaceutical Preparations

Keywords

  • Chemotherapy
  • Medication errors
  • MEDMARX
  • Oncology
  • Pediatrics

ASJC Scopus subject areas

  • Cancer Research
  • Oncology

Cite this

Characteristics of pediatric chemotherapy medication errors in a national error reporting database. / Rinke, Michael L.; Shore, Andrew D.; Morlock, Laura; Hicks, Rodney W.; Miller, Marlene R.

In: Cancer, Vol. 110, No. 1, 01.07.2007, p. 186-195.

Research output: Contribution to journalArticle

Rinke, Michael L. ; Shore, Andrew D. ; Morlock, Laura ; Hicks, Rodney W. ; Miller, Marlene R. / Characteristics of pediatric chemotherapy medication errors in a national error reporting database. In: Cancer. 2007 ; Vol. 110, No. 1. pp. 186-195.
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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.",
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N2 - 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.

AB - 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.

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