Can We Prevent Cytotoxic Disasters?

Fernandez, Conrad V.

doi:10.1046/j.1365-2141.2000.01797.x

Cited by 7 publications

(4 citation statements)

References 37 publications

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“…[24][25][26] Chen et al 13 published the results of a questionnaire to evaluate chemotherapy practices in the US. Overdoses of high-dose chemotherapy including two cases of busulfan overdose were investigated and recommendations for safeguards were proposed.…”

Section: Discussionmentioning

confidence: 99%

Accidental busulfan overdose during conditioning for stem cell transplantation

Jenke

Freiberg-Richter

Wilhelm

et al. 2004

Bone Marrow Transplant

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Summary:High dose busulfan is widely used in preparative regimens for bone marrow transplantation. We describe three cases of accidental busulfan overdosing. Two adults received a single dose of 8 and 18 mg/kg busulfan, respectively. Doses of 9 Â 4 mg/kg were ingested by a 14-year-old girl, who experienced seizures. In all cases, no severe liver toxicity including veno-occlusive disease was observed. Plasma samples were obtained from two patients. Busulfan plasma concentrations were far above published values after high-dose busulfan treatment. Busulfan was eliminated by a first-order process. All patients survived these high doses of busulfan and successful transplantation was possible. Two patients died from refractory GvHD on days 91 and 80 after transplantation. One patient is alive in remission after an observation time of 18 months. These cases show that busulfan overdosing may occur and pharmacokinetic evaluation is warranted to estimate risk of early and late toxicity.

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Section: Discussionmentioning

confidence: 99%

Accidental busulfan overdose during conditioning for stem cell transplantation

Jenke

Freiberg-Richter

Wilhelm

et al. 2004

Bone Marrow Transplant

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“…According to the 2012 US Department of Health and Human Services report, hospital incident reporting systems captured only an estimated 14% of the patient harm events experienced by Medicare beneficiaries . Due to incomplete reporting structures and the general paucity of systematic collection of data on “near misses,” it is challenging to ascertain an accurate picture of the frequency and seriousness of chemotherapy errors . Therefore, the quality and safety improvements arising from an inefficient reporting culture are suboptimal.…”

Section: Introductionmentioning

confidence: 99%

“…6 Due to incomplete reporting structures and the general paucity of systematic collection of data on "near misses," it is challenging to ascertain an accurate picture of the frequency and seriousness of chemotherapy errors. 7 Therefore, the quality and safety improvements arising from an inefficient reporting culture are suboptimal.…”

Section: Introductionmentioning

confidence: 99%

Avoiding chemotherapy prescribing errors: Analysis and innovative strategies

Reinhardt

Otte

Eggleton

et al. 2019

Cancer

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Background At Freiburg University Medical Center, chemotherapy prescriptions are processed via a computerized physician order entry (CPOE) tool and clinically checked by a designated chemotherapy surveillance team. Any error detected is reported instantly, corrected, and prospectively recorded. The objective of the current study was to gain insight into the causes, potential consequences, and future preventability of chemotherapy prescribing errors. Methods A detailed analysis of 18,823 consecutive antineoplastic orders placed in 2013 through 2014 was performed. In cooperation with information technology (IT) specialists, the intercepted errors were analyzed for effective future prevention using IT measures. Potential error consequences were determined by case discussions between pharmacists and physicians. Results Within 24 months, a total of 406 chemotherapy prescribing errors were intercepted that affected 375 (2%) of the total orders. Errors were classified as clinically relevant in 279 of the chemotherapy orders (1.5%). In these cases, reduced therapeutic efficacy (0.44%), the need for increased monitoring (0.48%), prolonged hospital stay (0.55%), and fatality (0.02%) were avoided as potential consequences. The most efficient conventional measures for error prevention comprised checking the order history and patient’s medical record, and a detailed knowledge of chemotherapy protocols. Of all the errors analyzed, 61% would be avoided through further software development. The improvements identified are implemented through a validated next‐generation CPOE tool. Conclusions The upgraded CPOE tool can be shared across other hospitals to raise safety standards and spread potential benefits across a wider patient population. The current analysis also highlighted that approximately 30% to 40% of errors cannot be avoided electronically. Therefore, pharmacovigilance initiatives remain indispensable.

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“…Fernandez (2000) refers to the continuing toll of cytotoxic disasters, including the inadvertent use of vincristine by the intrathecal route. Many of the more complex errors can perhaps only be prevented by the type of detailed analysis and safety programme implementation that he suggests.…”

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confidence: 99%