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Cases & Commentaries
- Web M&M
Jason Bergsbaken, PharmD; September 2018
A woman with cancer was admitted to begin a chemotherapy cycle of IV etoposide (daily for 3 days) and IV cisplatin (single dose). At the hospital's cancer center satellite pharmacy, the pharmacist entered the order into the computer and prepared the first dose of the medications. While transcribing the order, the pharmacist inadvertently switched the duration of therapy for the two agents. The transposition did not affect the patient's first day of therapy. The second day fell on a Saturday, when the satellite pharmacy was closed; a different pharmacist who did not have access to the original chemotherapy order prepared the therapy order. Cisplatin was labeled, dispensed, and reached the bedside. The nurse bypassed the double-check policy for verifying the order prior to administration, and the patient received the second dose of cisplatin instead of the intended dose of etoposide.
Journal Article > Commentary
Schulmeister L. Clin J Oncol Nurs. 2006;10:35-41.
The author explains how similar product names and labels contribute to medication errors in cancer treatment and shares risk reduction strategies to minimize such mistakes.