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Improving IV Insulin Administration in a Community Hospital

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Drug administration error related to computerized prescribing.

P Le Garlantezec¹, O Aupée, D Alméras

¹Hôpital d'instruction des armées du Val de Grâce, Pharmacy Department, Paris, France. le.garlantezec.pharm@gmail.com

Journal of Oncology Pharmacy Practice : Official Publication of the International Society of Oncology Pharmacy Practitioners

|October 17, 2009

Summary

Computerized prescribing aims to reduce medication errors, but a vincristine administration error occurred due to incorrect programming. Improved protocols and pharmacist/nurse training are crucial for preventing such errors.

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Area of Science:

Oncology
Pharmacology
Patient Safety

Background:

Computer-based prescribing systems were implemented to minimize medication errors.
Despite advancements, new types of prescribing and administration errors persist.

Observation:

A case report details a medication error involving vincristine, an antineoplastic agent.
The drug was administered subcutaneously instead of intravenously due to a programming error in the protocol.

Findings:

The incorrect administration route led to cutaneous erythema in the patient.
The error originated from a programming mistake in the administration route, missed by both the pharmacist and physician.
The pharmacist, responsible for order validation, compounding, and dispensing, failed to identify the critical error.

Implications:

Highlights the necessity for robust, validated therapeutic protocols within databases to ensure safe computer-based prescribing.
Emphasizes the need for enhanced training for nurses and pharmacists to detect novel medication errors and periodically review protocols.