Chemotherapy error: Analysis of an error reporting database, recent case reports, error reduction methods, current reporting systems

Abstract

6091 Background: Medical error, including cancer chemotherapy error (CE), is a significant national concern. CE is among the most serious type of medical error due to high potential of chemotherapy for toxicity and narrow therapeutic index. Chemotherapy is given to patients physiologically compromised by underlying disease, further amplifying risk for harm. Therefore, CE is an important issue for evaluation and remedial action. Methods: Current status of CE was evaluated through: 1) query and analysis of U.S. Pharmacopeia (USP) database of medication errors and 2) literature review to identify recent case reports of CE. Remedial actions to reduce CE were evaluated by identifying error reduction strategies and CE reporting methodologies via web and literature search. Telephone and e-mail queries were also utilized. Results: There were 296 episodes of CE involving 30 common chemotherapeutic agents found in the USP database from 1998–2002. A contemporaneous literature review was also performed. Table 1 provides the details of both. A compilation of error reduction strategies identified was compiled. Our search identified no comprehensive systems for detection, reporting, evaluation or system refinement related to CE. Conclusions: Analysis of CE reporting suggests avenues for remedial action. A universal system for CE reporting with simple reporting format, non-punitive review, and expert feedback could encourage more comprehensive reporting of CE. This would lead to more robust understanding, in turn promoting changes in policies/procedures, ultimately reducing CE and improving patient safety. No significant financial relationships to disclose.