Improving patient safety by minimizing chemotherapy dosing errors.

Abstract

99 Background: Medication dosing errors in adult outpatient settings continues to be a significant source of morbidity. One recent study reported that approximately 7% of adult patients receiving chemotherapy experience medication errors (Kathleen E. Walsh, et al. Medication Errors Among Adults and Children with Cancer in the Outpatient Setting, Journal of Clinical Oncology, 2009). In 2011, New Century Health implemented a quality improvement project focused on minimizing chemotherapy medication errors. This study describes the oncology quality management program used with the Midwestern oncology providers of a large health plan. Methods: An analysis determined the overall medication dosing error rate and the number of oncologist-to-oncologist interventions. In addition, the root cause of each medication error was identified. Results: During the course of the year, 2,395 chemotherapy treatment plans were reviewed for compendia alignment. In 235 cases, the plans did not align with compendia, were identified for peer-to-peer consultation and were voluntarily withdrawn by the prescriber. Evidence-based plans were subsequently resubmitted for approval. Of the original treatment plans, 68 contained dosing errors. The most common dosing errors included: frequency (60.3%); sub-therapeutic (13.1%); super-therapeutic (14.7%); and loading dose for continuation (10.3%). The full year 2011 medication error rate was 2.8%. Conclusions: The integration of clinical decision support tools for dosing verification with oncologist-to-oncologist clinical review improved patient safety by identifying serious errors prior to treatment. These findings underscore the issue that many chemotherapy medication errors are preventable and arguably the medication error rate should be zero. [Table: see text]