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Characteristics of pediatric chemotherapy medication errors in a national error reporting database
Michael L Rinke1, Andrew D Shore, Laura Morlock
1Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
Cancer
|May 29, 2007
Summary
Pediatric chemotherapy errors frequently reached patients, with administration and dispensing errors being most common. Methotrexate and cytarabine were frequently involved, highlighting the need for targeted safeguards in pediatric cancer care.
Area of Science:
- Pediatric Oncology
- Medication Safety
- Pharmacovigilance
Background:
- Limited data exists on chemotherapy medication errors in pediatric patients.
- Pediatric medication errors are reported at high rates overall.
- This study investigates patterns in pediatric chemotherapy errors.
Purpose of the Study:
- To examine patterns in pediatric chemotherapy medication errors.
- To identify common error types, causes, and involved agents.
- To inform the development of targeted medication administration safeguards.
Main Methods:
- Utilized the United States Pharmacopeia MEDMARX database.
- Analyzed error reports from 1999-2004 for patients under 18.
- Focused on reports involving chemotherapy medications.
Main Results:
- 310 pediatric chemotherapy error reports were analyzed; 85% reached the patient.
- Administration (48%) and dispensing (30%) phases were primary error origins.
- Antimetabolites were most frequent (39.5%), with methotrexate and cytarabine commonly involved.
- Improper dose/quantity (22.9%) and wrong time (22.6%) were leading error types.
- Performance deficit (41.3%) was the most cited cause of errors.
Conclusions:
- Pediatric chemotherapy errors are common, often reach patients, and can cause harm.
- Errors differ between outpatient and inpatient settings.
- Administration errors and specific agents like methotrexate require focused safety interventions.
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