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Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued this alert to bring attention to a rare but potentially severe administration error reported with the cancer drug vincristine. A previous editorial discusses similar errors.
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.
Journal Article > Study
Walsh KE, Dodd KS, Seetharaman K, et al. J Clin Oncol. 2009;27:891-896.
Medication errors in patients with cancer are a known safety concern, both with chemotherapy orders and with potential drug interactions and duplicate prescriptions. This study examined nearly 1500 adult and pediatric outpatient visits involving 12,000 medications to describe the prevalence and potential prevention strategies for medication errors. Error rates were found to be 7.1% in the adult visits and 18.8% in the pediatric visits with more than half of all errors occurring during administration. The latter finding was notable because investigators discovered that administration errors often resulted from confusion over two sets of orders written at different times. The authors advocate for greater attention to and communication about error prevention strategies given the trend toward cancer treatment in the outpatient setting.