Skip to main content

Abstract

Pediatric hematology oncology patients are at risk for medication and chemotherapy administration errors, which can lead to significant morbidity and mortality. Proper measurement and identification of medication errors are imperative to improvement, and chemotherapy error rates can be reduced through standardization of processes and continuous process improvement. To ensure sustainability, organizations should adopt a culture of safety and transparency.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Walsh KE, Dodd KS, Seetharaman K, et al. Medication errors among adults and children with cancer in the outpatient setting. JCO. 2009;27(6):891–986.

    Article  Google Scholar 

  2. Levy J. In my opinion: if measurement is critical to business success, why don’t executives measure the things that matter? CIO Enterprises, Sept 1999. 1992.

    Google Scholar 

  3. Aronson JK. Medication errors: definitions and classification. Br J Clin Pharmacol. 2009 Jun;67(6):599–604. doi:10.1111/j.1365-2125.2009.03415.x.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. Lancet. 2000;356(9237):1255–9.

    Article  CAS  PubMed  Google Scholar 

  5. Nebeker JR, Hurdle JF, Hoffman J, Roth B, Weir CR, Samore MH. Developing a taxonomy for research in adverse drug events: potholes and signposts. In: Proceedings of the AMIA Symposium. 2001. pp. 493–497.

    Google Scholar 

  6. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Taxonomy of Medication Errors; Available at http://www.NCCMERP.org. Accessed 25 Mar 2016.

  7. Goldspiel B, Hoffman JM, Griffith NL, Goodin S, DeChristoforo R, Montello CM, Chase JL, Bartel S, Patel JT. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm. 2015 Apr 15;72(8):e6–e35. doi:10.2146/sp150001.

    Article  PubMed  Google Scholar 

  8. Voeffray M, Pannatier A, Stupp R, Fucina N, Leyvraz S, Wasserfallen JB. Effect of computerization on the quality and safety of chemotherapy prescription. Qual Saf Health Care. 2006 Dec;15(6):418–21.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Institute of Medicine (IOM). In: Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.

    Google Scholar 

  10. Classen DC, Metzger J. Improving medication safety: the measurement conundrum and where to start. Int J Qual Health Care. 2003 Dec;15(Suppl 1):i41–7.

    Article  PubMed  Google Scholar 

  11. Meyer-Massetti C, Cheng CM, Schwappach DL, Paulsen L, Ide B, Meier CR, Guglielmo BJ. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011;68(3):227–40. doi:10.2146/ajhp100019.

    Article  PubMed  Google Scholar 

  12. Phillips MA. Voluntary reporting of medication errors. Am J Health Syst Pharm. 2002;59(23):2326–8.

    PubMed  Google Scholar 

  13. Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med. 2003;18(1):61–7.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2006;184(10 Suppl):S65–8.

    PubMed  Google Scholar 

  15. The Patient Safety and Quality Improvement Act of 2005. Overview, 2008. Agency for Healthcare Research and Quality, Rockville. http://www.ahrq.gov/qual/psoact.htm.

  16. MEDMARX. Quantros, Inc. Available at: https://www.medmarx.com. Accessed 25 Mar 2016.

  17. MedWatch: The FDA Safety Information and Adverse Event Reporting Program. US Food and Drug Administration, Center for Drug Evaluation and Research. http://www.fda.gov/medwatch/. Accessed 25 Mar 2016.

  18. Farley DO, Haviland A, Champagne S, Jain AK, Battles JB, Munier WB, Loeb JM. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008;17(6):416–23. doi:10.1136/qshc.2007.024638.

    Article  CAS  PubMed  Google Scholar 

  19. Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008;17(6):400–2. doi:10.1136/qshc.2008.029496.

    Article  PubMed  Google Scholar 

  20. Jha AK, Kuperman GJ, Teich JM, Leape L, Shea B, Rittenberg E, Burdick E, Seger DL, Vander Vliet M, Bates DW. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc. 1998;5(3):305–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114–20.

    Article  CAS  PubMed  Google Scholar 

  22. Kaushal R. Using chart review to screen for medication errors and adverse drug events. Am J Health Syst Pharm. 2002;59(23):2323–5.

    PubMed  Google Scholar 

  23. Manias E. Detection of medication-related problems in hospital practice: a review. Br J Clin Pharmacol. 2013;76(1):7–20. doi:10.1111/bcp.12049. Review

    Article  PubMed  Google Scholar 

  24. Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R. Development and evaluation of the Institute for Healthcare Improvement Global Trigger Tool. J Patient Saf. 2008;4(3):169–77.

    Article  Google Scholar 

  25. Griffin FA, Resar RK. IHI global trigger tool for measuring adverse events, IHI innovation series white paper. 2nd ed. Cambridge: Institute for Healthcare Improvement; 2009. Available on www.IHI.org

    Google Scholar 

  26. Stockwell DC, Kirkendall E, Muething SE, Kloppenborg E, Vinodrao H, Jacobs BR. Automated adverse event detection collaborative: electronic adverse event identification, classification, and corrective actions across academic pediatric institutions. J Patient Saf. 2013;9(4):203–10. doi:10.1097/PTS.0000000000000055.

    Article  PubMed  Google Scholar 

  27. Ferranti J, Horvath MM, Cozart H, Whitehurst J, Eckstrand J. Reevaluating the safety profile of pediatrics: a comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment. Pediatrics. 2008;121(5):e1201–7. doi:10.1542/peds.2007-2609.

    Article  PubMed  Google Scholar 

  28. Kilbridge PM, Noirot LA, Reichley RM, Berchelmann KM, Schneider C, Heard KM, Nelson M, Bailey TC. Computerized surveillance for adverse drug events in a pediatric hospital. J Am Med Inform Assoc. 2009;16(5):607–12. doi:10.1197/jamia.M3167. Epub 2009 Jun 30

    Article  PubMed  PubMed Central  Google Scholar 

  29. Call RJ, Burlison JD, Robertson JJ, Scott JR, Baker DK, Rossi MG, Howard SC, Hoffman JM. Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population. J Pediatr. 2014;165(3):447–52.e4. doi:10.1016/j.jpeds.2014.03.033. Epub 2014 Apr 25

    Article  PubMed  PubMed Central  Google Scholar 

  30. Hope C, Overhage JM, Seger A, Teal E, Mills V, Fiskio J, Gandhi TK, Bates DW, Murray MD. A tiered approach is more cost effective than traditional pharmacist-based review for classifying computer-detected signals as adverse drug events. J Biomed Inform. 2003;36(1–2):92–8.

    Article  PubMed  Google Scholar 

  31. Dormann H, Muth-Selbach U, Krebs S, Criegee-Rieck M, Tegeder I, Schneider HT, Hahn EG, Levy M, Brune K, Geisslinger G. Incidence and costs of adverse drug reactions during hospitalisation: computerised monitoring versus stimulated spontaneous reporting. Drug Saf. 2000;22(2):161–8.

    Article  CAS  PubMed  Google Scholar 

  32. Barker KN, McConnell WE. The problems of detecting medication errors in hospitals. Am J Hosp Pharm. 1962;19:360–9.

    Google Scholar 

  33. Barker KN, Flynn EA, Pepper GA. Observation method of detecting medication errors. Am J Health Syst Pharm. 2002;59(23):2314–6.

    PubMed  Google Scholar 

  34. David BA, Rodriguez A, Marks SW. Risk reduction and systematic error management: standardization of the pediatric chemotherapy process. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in patient safety: new directions and alternative approaches (Vol 2: Culture and Redesign). Rockville: Agency for Healthcare Research and Quality (US); 2008.

    Google Scholar 

  35. Fisher DS, Alfano S, Knobf MT, Donovan C, Beaulieu N. Improving the cancer chemotherapy use process. J Clin Oncol. 1996;14:3148–55.

    Article  Google Scholar 

  36. Leape L. Error in medicine. JAMA. 1994;272(23):1851–7.

    Article  CAS  PubMed  Google Scholar 

  37. ASHP. Guidelines on Preventing Medication Errors in Hospitals.

    Google Scholar 

  38. Institute for Safe Medication Practices. Guidelines for Standard Order Sets 2010. Available from http//www.ismp.org/Tools/guidelines/StandardOrderSets.pdf. Accessed 23 Mar 2016.

  39. Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care. 2007;16:116–26.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Dinning C, Branowicki P, O’Neill JB, Marino BL, Billet A. Chemotherapy error reduction: a multidisciplinary approach to create templated order sets. J Pediatr Oncol Nurs. 2005;22(1):20–30.

    Article  PubMed  Google Scholar 

  41. Kohler DR, Montello MJ, Green L, et al. Standardizing the expression and nomenclature of cancer treatment regimens. Am J Health-Syst Pharm. 1998;55:137–44.

    CAS  PubMed  Google Scholar 

  42. Healthcare Human Factors. Guidelines for developing ambulatory chemotherapy preprinted orders. Centre for Global eHealth Innovation, University Health Network: Toronto, Ontario, Canada. Available from: http://www.capca.ca/wp-content/uploads/PPO-Guidelines-FINAL-Jan-9-20111.pdf. Accessed 28 Mar 2016.

  43. Committee on Identifying and Preventing Medication Errors. Board on Health Care Services. Philip A, Wolcott JA, Bootman JL, Cronenwett LR, editors. Preventing medication errors. Washington, DC: Institute of Medicine of the National Academies. The National Academies Press.

    Google Scholar 

  44. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety. A systematic review. Arch Intern Med. 2003;163(12):1409–16.

    Article  PubMed  Google Scholar 

  45. Bonnabry P, Cingria L, Ackermann M, Sageghipour F, Bigler L, Mach N. Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int J Qual Health Care. 2006;18(1):9–16.

    Article  PubMed  Google Scholar 

  46. Robinson DL, Heigham M, Clark J. Using failure mode and effects analysis for safe administration of chemotherapy to hospitalized children with cancer. Jt Comm J Qual Patient Saf. 2006;32(2):161–6.

    Article  PubMed  Google Scholar 

  47. Baker DK, Hoffman JM, Hale GA, et al. Advances in patient safety: new directions and alternative approaches (Vol. 2: Culture and redesign). In:Analysis of patient safety: converting complex pediatric chemotherapy ordering processes from paper to electronic systems. Rockville: Agency for Healthcare Research and Quality (US); 2008.

    Google Scholar 

  48. Cohen MR. Medication errors. 2nd ed. Washington, DC: American Pharmacists Association; 2007.

    Book  Google Scholar 

  49. Bonnabry P, et al. A risk analysis method to evaluate the impact of a computerized provider order entry system on patient safety. J Am Med Inform Assoc. 2008;15:453–60.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Shulman LN, et al. Principles of safe practice using an oncology EHR system for chemotherapy ordering, preparation, and administration, part 2 of 2. J Oncol Pract. 2008;4(5):254–7.

    Article  PubMed Central  Google Scholar 

  51. Louis Harris and Associates. Public opinion of patient safety issues: research findings. Prepared for National patient safety foundation at AMA. September 1997. Available at: www.npsf.org/download/1997survey.pdf.

  52. Institute for Safe Medication Practices (ISMP). Independent double checks: Undervalued and misused: selective us of this strategy can play an important role in medication safety. ISMP Medication Safety Alert. June 13, 2013. Available at the ISMP website under newsletters.

    Google Scholar 

  53. ISMP. Safety Bulletin, Canada. Lowering the risk of medication errors: independent double checks. 2005;5(1). Available at the ISMP website under newsletters.

    Google Scholar 

  54. White RE, Trbovich PL, Easty AC, et al. Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Qual Saf Health Care. 2010;19(6):562–7.

    PubMed  PubMed Central  Google Scholar 

  55. Conway J, Nathan D, Benz E, et al. Key learning from the Dana-Farber Cancer Institute’s 10-year patient safety journey. J Clin Oncol. 2006;1092–9118:615–9.

    Google Scholar 

  56. National Patient Safety Foundation. Free from harm accelerating patient safety improvement fifteen years after To Err is Human. December 2015. Available at: www.npsf.org/free-from-harm.

  57. ASHP Policy 1021 Just Culture and Reporting Medication Errors available at: http://www.ashp.org/import/practiceand policy/policypostionsguidelinesbestpractices.aspx.

  58. Conway J. Taking it to the Top. Hospital and Health Networks. March 2000; p. 100.

    Google Scholar 

  59. Connor M, Duncombe D, Barclay E, et al. Creating a fair & just culture: one institutions path toward organizational change. J Qual Patient Safety. 2007;33(10):617–24.

    Article  Google Scholar 

  60. ISMP International Medication Safety Self-Assessment for Oncology. 2012; Available at:http://mssa.ismp-canada.org/oncology.

  61. ISMP. Targeted medication safety best practices for hospitals. 2014:19(1). 2014–2015. Available at the ISMP website under newsletters.

    Google Scholar 

  62. ISMP. Targeted medication safety best practices for hospitals. 2016:21(3). 2016–2017. Available at the ISMP website under newsletters.

    Google Scholar 

  63. ISMP medication safety alert—selected medication safety risks to manage in 2016 that Might Otherwise Fall off the Radar Screen—part 1. 2016:21(2). 2016–2017. Available at the ISMP website under newsletters.

    Google Scholar 

  64. ISMP medication safety alert—selected medication safety risks to manage in 2016 that Might Otherwise Fall off the Radar Screen—part II. 2016:21(3). 2016–2017. Available at the ISMP website under newsletters.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Sylvia Bartel .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing AG

About this chapter

Cite this chapter

Bartel, S., Szabatura, A.H., Moore, C. (2017). Chemotherapy and Medication Safety. In: Dandoy, C., Hilden, J., Billett, A., Mueller, B. (eds) Patient Safety and Quality in Pediatric Hematology/Oncology and Stem Cell Transplantation. Springer, Cham. https://doi.org/10.1007/978-3-319-53790-0_10

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-53790-0_10

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-53788-7

  • Online ISBN: 978-3-319-53790-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics