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Search results for "Active Errors"

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Journal Article > Commentary

Two fatal cases of accidental intrathecal vincristine administration: learning from death events.

Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Chemotherapy. 2015;61:108-110.

Incorrectly administered vincristine can lead to serious adverse consequences. Discussing two incidents involving accidental intrathecal vincristine administration, this commentary describes how the health care organization implemented changes (including using different bags for drugs and label colors for syringes) following the first event and made further revisions when the second incident occurred 7 years later (such as ensuring drugs are delivered during different times and in certain settings).

Journal Article > Study

Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.

Greenall J, Shastay A, Vaida AJ, et al. J Oncol Pharm Pract. 2015;21:26-35.

In 2012, more than 350 organizations from 13 countries participated in the initial Institute for Safe Medication Practices self-assessment for oncology. This study describes results from this baseline survey, which revealed key opportunities for improvements in the safe delivery of chemotherapy. For example, many institutions have still not followed best practices for the administration of vincristine. In addition, less than half of respondents had fully implemented safety processes for oral chemotherapy orders. A prior AHRQ WebM&M commentary describes a patient who inadvertently received the wrong chemotherapy regimen and explores the high risks associated with inpatient chemotherapy.

Journal Article > Review

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use.

Kukreti V, Cosby R, Cheung A, Lankshear S; ST Computerized Prescriber Order Entry Guideline Development Group. Curr Oncol. 2014;21:e604-e612.

Medication error rates are extremely high among patients receiving outpatient chemotherapy. This systematic review found a paucity of studies on the effectiveness of computerized provider order entry (CPOE) in improving the safety of chemotherapy, but concluded that the limited evidence supports wider use of CPOE in this setting.

Newspaper/Magazine Article

With oral chemotherapy, we simply must do better!

ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.

To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.

Journal Article > Study

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

Prakash V, Koczmara C, Savage P, et al. BMJ Qual Saf. 2014;23:884-892.

This study used high-fidelity simulation to evaluate the impact of several interventions on preventing medication administration errors by chemotherapy nurses. Interventions with a basis in human factors engineering principles appeared to be highly effective at reducing errors related to interruptions.

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.

Journal Article > Review

Quality and safety in pediatric hematology/oncology.

Mueller BU. Pediatr Blood Cancer. 2014;61:966-969.

Children with cancer are particularly vulnerable to medication errors. This review describes how to enhance safe medication use in pediatric oncology through establishing a safety culture, integrating high reliability principles, and teamwork training.

Journal Article > Study

Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists.

Gilbar P, Chambers CR, Larizza M. J Oncol Pharm Pract. 2015;21:10-18.

The chemotherapy drug vincristine almost always causes fatal toxicity if it is incorrectly administered intrathecally (via spinal injection) rather than intravenously. This hazard is well publicized, but accidental administration of intrathecal vincristine continues to occur. This survey of oncology pharmacists found that many pharmacies still lack appropriate safeguards to prevent such errors.

Journal Article > Study

Improving cancer patient care with combined medication error reviews and morbidity and mortality conferences.

Ranchon F, You B, Salles G, et al. Chemotherapy. 2014;59:330-337.

This case series study describes 10 medication errors related to cancer treatment that were investigated using an approach incorporating root cause analysis and a morbidity and mortality conference. This process resulted in the proposal of multiple corrective actions, suggesting that it identifies actionable safety concerns.

Newspaper/Magazine Article

Understanding and managing IV container overfill.

ISMP Medication Safety Alert! Acute Care Edition. November 14, 2013;18:1-4.

This newsletter article reports on concerns associated with chemotherapy preparations due to variations in concentration and recommends standardized preparation processes to address such risks.

Journal Article > Review

Intrathecal chemotherapy: potential for medication error.

Gilbar PJ. Cancer Nurs. 2014;37:299-309.

This systematic review of intrathecal chemotherapy—medications injected directly into the space surrounding the spinal cord—demonstrates that it is an important source of fatal medication errors. The author identifies strategies to decrease risks related to intrathecal chemotherapy, including avoiding syringe use for administration.

Newspaper/Magazine Article

Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0.

ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013;18:1-4.

This newsletter article discusses risks associated with vincristine administration, contributing factors, and strategies to prevent errors.

Journal Article > Study

Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study.

White R, Cassano-Piché A, Fields A, Cheng R, Easty A. J Oncol Pharm Pract. 2014;20:40-46.

A fatal chemotherapy medication error prompted this thorough examination of ambulatory intravenous chemotherapy processes in Canada. This study uncovered potential preparation errors that were previously unrecognized and could lead to serious patient harms.

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 > Commentary

Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors.

Ewen BM, Combs R, Popelas C, Faraone GM. Home Healthc Nurse. 2012;30:28-37.

This commentary describes how a medication administration error launched one organization's efforts to improve patient safety statewide.

Audiovisual

Pharmacy mixes up prescriptions.

Haythorn R. ABC News. February 7, 2011.

This video news segment reports on a pharmacy error involving similar patient names. A pregnant woman was mistakenly given a chemotherapy medication instead of an antibiotic.

Journal Article > Study

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

This study describes how implementation of a computerized provider order entry system reduced errors associated with prescribing oral chemotherapy.

Journal Article > Commentary

Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

Reddy GK, Brown B, Nanda A. Clin Neurol Neurosurg. 2011;113:68-71.

This case report describes a vincristine administration error and recommends strategies to prevent similar incidents.

Journal Article > Study

Computerized physician order entry of injectable antineoplastic drugs: an epidemiologic study of prescribing medication errors.

Nerich V, Limat S, Demarchi M, et al. Int J Med Inform. 2010;79:699-706.

The incidence of prescribing errors for chemotherapy drugs remained relatively high in this study, at 10 per 1000 orders, despite use of a computerized provider order entry system.

Newspaper/Magazine Article

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.

This article discusses a case of data entry error in an electronic prescribing system, explains the contributing factors, and provides recommendations to prevent such errors.

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