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- Communication Improvement 3
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 2
- Human Factors Engineering 3
- Legal and Policy Approaches 2
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Technologic Approaches 1
Search results for "Chemotherapeutic Agents"
- Chemotherapeutic Agents
- Cognitive Errors ("Mistakes")
Journal Article > Study
Carrez L, Bouchoud L, Fleury S, et al. J Oncol Pharm Pract. 2019 May 13; [Epub ahead of print].
This simulation study compared performance of pharmacists in preparing chemotherapy under conditions of increasing workload, as measured by the number of doses needed. Investigators found that as the volume of work increased, so did the risk of errors. This finding highlights the need to ensure working conditions promote safety.
Cases & Commentaries
- Web M&M
Jennifer Faig, MD, and Jessica A. Zerillo, MD, MPH; June 2018
Admitted to the oncology service for chemotherapy treatment, a woman with leukemia was noted to be neutropenic on hospital day 6. She had some abdominal discomfort and had not had a bowel movement for 2 days. The overnight physician ordered a suppository without realizing that the patient was neutropenic and immunosuppressed. Unaware that suppositories are contraindicated in neutropenic patients, the nurse administered the suppository. The patient developed a fever soon after receiving the suppository and required transfer to the intensive care unit for hypotension and management of septic shock.
Journal Article > Study
Prioritizing medication safety in care of people with cancer: clinicians' views on main problems and solutions.
Car LT, Papachristou N, Urch C, et al. J Glob Health. 2017;7:011001.
Patients with cancer are at increased risk of medication errors in both the inpatient and outpatient settings. In this study, investigators solicited input from cancer care clinicians regarding their perception of causes and potential solutions for medication errors. Clinicians identified limited health literacy and inadequate information sharing among clinicians as barriers to providing safe care and they suggested increased patient engagement as one potential approach to improving safety.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
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.
Journal Article > Commentary
Berwick DM. BMJ. 2001;322:247-248.
In this editorial, the author responds to an error involving intrathecal administration of vincristine and emphasizes that a commitment to design change can improve safety.
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.
Information Exchange System Alert. Geneva, Switzerland: World Health Organization; July 18, 2007.
This international announcement provides guidance on the safe administration of the chemotherapeutic agent vincristine.
Fernandez J. Drug Topics. May 7, 2007.
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken against the pharmacist involved.