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Analysis of Chemotherapy Prescribing Errors Detected by Pharmacists  

Lee, Hyun-Ju (Department of Pharmacy, Yonsei University Medical Center)
Yang, Mi-Kyung (Department of Pharmacy, Yonsei University Medical Center)
Jo, Ju-Hee (Department of Pharmacy, Yonsei University Medical Center)
Kim, Sung-Eun (Department of Pharmacy, Yonsei University Medical Center)
Seok, Hyun-Ju (Department of Pharmacy, Yonsei University Medical Center)
Kim, Hyun-Ah (College of Pharmacy, Seoul National University)
Publication Information
Korean Journal of Clinical Pharmacy / v.20, no.2, 2010 , pp. 120-127 More about this Journal
Abstract
Objective: The purpose of this study was to identify the type and frequency of chemotherapy-related prescribing errors and assess the pharmacist intervention in preventing potential harm. Methods: This study was performed in satellite pharmacy of oncology/hematology unit in tertiary teaching hospital from April to September, 2009. All chemotherapy prescribing errors detected by pharmacists were recorded. Frequency and characteristics of prescribing errors were analyzed. Pharmacists reviewed 28, 495 chemotherapy orders from 12,719 patients during 6-month periods. Results: A total of 835 prescription errors (2.93%) in 734 patients (5.77%) were detected by pharmacists. Alkylating agents (37.6%) followed by antimetabolite (23.35%), and mitotic inhibitors (21.44%) were the most prevalent classes in which errors occurs. The most common types of error detected were incorrect dose (34%), incorrect solution (33%), incorrect route (9%) and omission errors (8%). Changes in chemotherapy order due to pharmacists' intervention occurred in all error cases. Conclusion: Pharmacists' intervention in reviewing chemotherapy and drug orders intercepted potential harm due to prescribing errors. The current study provided strategies for reduction of medication errors.
Keywords
Chemotherapy; Prescribing errors; Pharmacists' intervention;
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1 Broyles JE, Brown RO, Vehe KL, et al., Pharmacist interventions improve fluid balance in fluid restricted patients requiring parenteral nutrition. Ann Pharmacother 1991; 25: 119-22.
2 Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital. Pharmacotherapy 2009; 29: 966-74.   DOI   ScienceOn
3 Folli HL, Poople RL, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987; 79: 718-22.
4 Lustig A. Medication error prevention by pharmacists - An Israeli solution. Pharm World Sci 2000; 22; 21-25.   DOI   ScienceOn
5 Estellat C, Colombet I, Vautier S, Huault-Quentel J, Durieux P, Sabatier B. Impact of pharmacy validation in a computerized physician order entery context. Int J Qual Health Care 2007; 19: 317-25.   DOI   ScienceOn
6 Warholak TL, Rupp MT. Analysis of community chain pharmacists' interventions on electronic prescriptions. J Am Pharm Assoc 2009; 49: 59-64.   DOI   ScienceOn
7 Phillps J, Beam S, Brinker A, et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001; 58: 1835-41.
8 Rinke ML, Shore AD, Morlock L, Hicks RW, Miller MR. Characteristics of pediatric chemotherapy medication errors in a National error reporting database. Cancer 2007; 110: 186-95.   DOI   ScienceOn
9 Lewis PJ. Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients. A systemic review. Drug Safety 2009; 32: 379-89.   DOI   ScienceOn
10 Brown JN, Barnes CL, Beasley B, Cisneros R. Effect of pharmacists on medication errors in an emergency department. Am J Health-Syst Pharm 2008; 65(4): 330-33.   DOI   ScienceOn
11 Ford CD, Killebrew J, Fugitt P, Jacoben J, Prystas EM. Study of medication errors on a community hospital oncology ward. J Oncol Pract 2006; 2: 149-53.   DOI
12 Gandhi TK, Bartel SB, Shulman LN, Medication safety in the ambulatory chemotherapy setting. Cancer 2005; 104: 2477-83.
13 Valentin A, Capuzzo M, Guidet B et al., Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 2009; 338: b814.   DOI
14 Schulmeister L. Preventing chemotherapy errors. The Oncologist 2006; 11: 463-68.   DOI   ScienceOn
15 Kohn LT, Corrigan J, Donaldson MS. To error is human: building a safer health system. Washington, DC: National Academy Press, 2000: xxi, 287.
16 국가 암 정보 센터 website. Available at: www.cancer.go.kr
17 Kloth DD. Prevention of chemotherapy medication errors. Journal of Pharmacy Practice 2002; 15: 17-31.   DOI   ScienceOn
18 Leape LL, Cullen DJ, Clapp MD, et al., Pharmacist participation on physician rounds and adverse drug events in the intensive care units. JAMA 1999; 282: 267-70.   DOI   ScienceOn
19 Bates DW, Cullen DJ, Laird NM, et al., Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995; 274: 29-34.   DOI   ScienceOn
20 Cohen MR. American Pharmaceutical Association. Medication Errors. Washington, DC: American Pharmaceutical Association, 1999; 18.16-18.17.
21 Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized patients. J Gen Intern Med 1993; 8: 289-94.   DOI   ScienceOn
22 Seeley CE, Nicewander D, Page R, Dysert PA. A baseline study of medication error rates at Baylor University Medical Center in preparation for implementation of a computerized physician order entry system. BUMC Proceedings 2004; 17: 357-61.
23 Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997; 277: 312-17.   DOI   ScienceOn