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Paul R. Drug Topics. September 17, 2007;151:10.
This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
Journal Article > Study
Weingart SN, Toro J, Spencer J, et al. Cancer. 2010;116:2455-2464.
Widely publicized errors associated with chemotherapy catalyzed extensive efforts to improve safety for patients receiving traditional intravenous chemotherapy. However, an increasing number of cancer patients are prescribed oral chemotherapy, and a prior study found that most cancer centers lack formal safety protocols for these medications. This AHRQ-funded analysis used multiple data sources to identify and characterize oral chemotherapy medication errors, and found that most errors resulted from dispensing incorrect dosages or medications—similar to prior studies of outpatient chemotherapy errors. The authors conclude that standardized safety practices for oral chemotherapy are urgently needed.
Journal Article > Review
'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care—a review of the literature.
Kullberg A, Larsen J, Sharp L. Eur J Oncol Nurs. 2013;17:228-235.
Cancer patients undergoing chemotherapy may be particularly vulnerable to medical errors, as their care often requires use of high-risk medications and must be closely coordinated between multiple physicians. This thematic review focused on methods to improve safety for chemotherapy patients and found evidence that computerized provider order entry could reduce medication errors. However, the authors did not find enough evidence to recommend other interventions that have been proposed, such as patient engagement or teamwork training for patients and families. An AHRQ WebM&M commentary discusses how one institution responded to a serious chemotherapy error.
Journal Article > Study
Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.
Franklin BD, Panesar SS, Vincent C, Donaldson LJ. BMJ Qual Saf. 2014;23:765-772.
Although there have been no reported accidental spinal injection of a vinca alkaloid in the United Kingdom since 2001, this study looked at upstream safety issues that could cause this fatal complication. The method used in this study provides a model for evaluating the resilience of safety practices, even in the absence of actual harmful events.