Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Abstract

Background: To reduce the occurrence of medication errors, a systemic approach was developed combining anti-neoplastic medication error reviews and morbidity and mortality conferences (M&MCs). We report the first experience of implementing this strategy in oncology. Methods: The case reports submitted to combined reviews were prepared by physicians and pharmacists, and medication error(s) were described and chronological and root-cause analyses were performed. Results: Ten combined reviews were conducted, which involved the departments of haematology, medical oncology, pneumology, gastroenterology and clinical oncology pharmacy. A total of 91 errors were analysed, of which 3 had reached the patient. Thirty-four corrective actions were proposed; 53% consisted of changes in practice, 35% in procedural reminders and 12% in on-ward education sessions. Conclusions: The combination of medication error reviews and M&MCs appears to be an efficient means of improving cancer patient safety and personnel proficiency. This multidisciplinary work is indispensable to improve future patient management through the critical analysis of past medical errors.

EPICC study: evaluation of pharmaceutical intervention in cancer care

“…Some are familiar to all healthcare professionals and widely prescribed in daily practice, for example paracetamol, zopiclone and zolpidem . In the present study, platinum agents accounted for 25% of DRPs, in agreement with our previous study of antineoplastic medication error reviews and morbidity and mortality conferences (M&MCs) . This high rate of PIs involving carboplatin is related to the particular way of dosing this drug, using AUC.…”

“…This high rate of PIs involving carboplatin is related to the particular way of dosing this drug, using AUC. Antineoplastic medication error reviews and M&MCs were helpful in developing prevention tools: computerized formulae for calculating carboplatin doses according to the Chatelut or Calvert formulae, or Thomas's modified formula for cachectic or obese patients . The effectiveness of these measures for risk prevention needs assessment in a further study.…”

Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy

“…Chemotherapy regimen prescription errors included the doses of anticancer drugs, intervals, adding or stopping anticancer drugs, chemotherapy regimen choice, and administration routes or rates, and these errors could have fatal consequences. 17 It is important to note that CPOE does not prevent all types of prescription errors, even with simple prescribing mistakes, because the computer system is unable to identify or judge the validity of the chemotherapy regimens. CPOE is only able to perform checks on basic items, such as dose calculation and the interval of chemotherapy.…”

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology

“…1.14 The health care setting has policy for reporting of adverse events and near misses and has a formal process for collecting and evaluating data at a defined frequency. 11,13,25,26 Domain 2: Treatment Planning, Patient Consent, and Education…”

“…Stress, understaffing, lack of experience, and unclear orders were cited as factors believed to contribute to the occurrence of errors. 9 As chemotherapy-related errors are intercepted at rates of approximately 2%-5%, [10][11][12] it is important to note that some types of errors are virtually undiscoverable without continuous monitoring of the preparation process. For example, a person who prepares drugs may select from the wrong drug supply and accidentally substitute one drug vial for another.…”