Design and implementation of a lomustine circuit as a safe practice.

Area of Science:

• Healthcare Safety
• Medication Management
• Oncology Pharmacy

Background:

• Patient safety is paramount in healthcare, with many errors occurring in challenging home environments.
• High-risk medications like lomustine require stringent safety protocols due to their potential for severe harm.
• Reason's model of error emphasizes system design to mitigate human errors.

Purpose of the Study:

• To investigate a medication error involving an overdose of lomustine.
• To design and implement a comprehensive medication circuit to prevent future errors.
• To improve patient safety in the administration of high-risk chemotherapy drugs.

Main Methods:

• A root cause analysis (RCA) was performed following a medication error incident.
• A collaborative multidisciplinary approach involving Oncology and Pharmacy departments was adopted.
• A structured medication circuit was developed, encompassing prescription, validation, custody, and dispensing stages.

Main Results:

• The RCA identified critical process points contributing to the lomustine overdose error.
• The implemented lomustine circuit successfully addressed identified vulnerabilities in the medication-use process.
• No further medication errors related to lomustine have been reported since the circuit's implementation.

Conclusions:

• A structured medication circuit is an effective strategy for eliminating medication errors with high-risk drugs like lomustine.
• The developed circuit significantly improved the safety and reliability of lomustine administration.
• This approach demonstrates the success of system-level interventions in enhancing patient safety in oncology care.