A study conducted by researchers at Dana-Farber Cancer Institute (DFCI) and Brigham and Women’s Hospital (BWH), and published in the online journal Cancer, evaluated chemotherapy errors that occur during outpatient care.
The researchers report that while the mistakes they found were not life-threatening, error prevention could still be more effective.
Both DFCI and BWHl, which are in the forefront of efforts to provide excellent standards of care and increased patient safety, consented to share drug-order and patient-safety records with investigators.
The research teams at the two institutions evaluated, over 10,000 medication orders from Dana-Farber’s adult and pediatric ambulatory oncology infusion clinics.
Researchers determined that 3% of the orders contained errors, one-third of which were considered serious. 82% of the errors in adults and 60% in children were found to be possibly hazardous.
Pharmacists and nurses, however, caught 45% of these dangerous errors before they reached patients, and none turned out to be detrimental.
The most common error in both the adult-clinic, which is computerized, and the pediatric clinic, which uses a paper system, was omitted or incorrect dosages and failure to discontinue orders.
The results show that, while safeguards such as computerized order-entry systems — used at both Dana-Farber and Brigham and Women’s — significantly reduce drug-order errors, additional improvements are still possible, and essential.
To address the problem with order errors, DFCI is implementing a series of new policies including the transfer of the pediatric clinic to computer orders.
In the adult clinics, the computer system has been upgraded to incorporate more detailed information. For example, physicians must now order drugs that need to be administered together simultaneously.