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Medication errors in cancer therapy: Reports from German hospital pharmacists between 2008 and 2019
Lisa Weber1, Claudia Langebrake2, Gesine Picksak3
1Hospital Pharmacy of the University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany.
Objective:
Since medication errors can have severe consequences, the development of methods to improve patient safety is becoming increasingly important. The aim of this evaluation was to identify frequent medication errors in oncology as well as characteristic correlations in the various error patterns. In addition, the implementation rate of the proposed pharmaceutical intervention was determined in order to assess the benefit of a clinical pharmacist in the field of oncology.
Methods:
The evaluation was based on a data-set from a national documentation system for medication errors and interventions (DokuPIK) used by hospital pharmacists in the field of oncology from 2008 to 2019, namely 6684 reported cases in oncology, representing about 5% of all reports in DokuPIK.
Results:
The most frequently reported errors were incorrect doses (22% of reported errors), followed by interactions (14%); in 10% of errors the prescription/documentation was incomplete/incorrect. The intervention suggested by the pharmacist was implemented in 97% of the cases. Based on the respective Anatomical Therapeutical Chemical Classification (ATC codes), drugs (or groups of drugs) were identified that were reported frequently in connection with medication errors, namely carboplatin and cyclophosphamide as anticancer drugs pantoprazole as non-anticancer drug.
Conclusion:
Frequently occurring medication errors in the field of oncology were identified, facilitating the development of specific recommendations for action and prevention strategies. The implementation of an electronic prescription software is particularly recommended for the avoidance of dosage errors in chemotherapy.
Insights
Medication errors in oncology, such as incorrect doses and interactions, were identified. Clinical pharmacist interventions were highly effective (97% implementation), highlighting their role in improving patient safety and preventing chemotherapy errors.
Area of Science:
- Oncology
- Pharmacology
- Patient Safety
Background:
- Medication errors in oncology can lead to severe patient harm.
- Improving patient safety through error reduction is a critical healthcare objective.
- Understanding error patterns is essential for developing effective prevention strategies.
Purpose of the Study:
- To identify frequent medication errors and their patterns in oncology.
- To determine the implementation rate of pharmaceutical interventions.
- To assess the benefit of clinical pharmacists in oncology patient safety.
Main Methods:
- Analysis of 6684 oncology medication error reports from the DokuPIK system (2008-2019).
- Identification of common error types, including incorrect doses, interactions, and documentation issues.
- Documentation of drug-specific error correlations using Anatomical Therapeutic Chemical (ATC) codes.
Main Results:
- Incorrect doses (22%) and drug interactions (14%) were the most frequent medication errors.
- Prescription or documentation errors occurred in 10% of cases.
- Pharmacist-recommended interventions were implemented in 97% of cases, with carboplatin, cyclophosphamide, and pantoprazole frequently implicated in errors.
Conclusions:
- Specific recommendations and prevention strategies for oncology medication errors can be developed based on identified patterns.
- Clinical pharmacists play a vital role in improving patient safety in oncology.
- Electronic prescription software is recommended to minimize chemotherapy dosage errors.
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