Mayank Dhamija1, Gauri Kapoor, Atul Juneja. 1. *Department of Pediatric Hematology and Oncology, Rajiv Gandhi Cancer Institute and Research Centre †National Institute of Medical Statistics, New Delhi, India.
Abstract
BACKGROUND: Drug administration is a multiprofessional process. The high toxicity and low therapeutic index of chemotherapy drugs make medication errors a significant problem, resulting in excessive patient morbidity and cost. OBJECTIVE: An audit of the delivery of infusional chemotherapy among pediatric inpatients was planned, with the objective of improving practice and minimizing errors. METHOD: An observational study was conducted between January and August 2012. Patients were followed up from their premedication until the completion of postchemotherapy hydration and/or rescue drugs. Errors were recorded and classified by error type, cause, severity, unit location, medication involved, and harm caused. RESULTS: A total of 205 observations were made and 23(13.6%) errors recorded, of which 6 were intercepted. No life-threatening adverse drug event was recorded. The most important risk factor predisposing to errors was admission to nonpediatric ward (P=0.004). Documentation errors and incorrect infusion time were the 2 most common errors, whereas the most frequent error node was administration error. Appropriate steps were taken to prevent their reoccurrence. CONCLUSIONS: This study helped provide important information about the rate and epidemiology of medication errors, emphasizing on the role of audit in enabling development of appropriate error-reducing strategies, particularly in the context of quality assurance in hospitals.
BACKGROUND: Drug administration is a multiprofessional process. The high toxicity and low therapeutic index of chemotherapy drugs make medication errors a significant problem, resulting in excessive patient morbidity and cost. OBJECTIVE: An audit of the delivery of infusional chemotherapy among pediatric inpatients was planned, with the objective of improving practice and minimizing errors. METHOD: An observational study was conducted between January and August 2012. Patients were followed up from their premedication until the completion of postchemotherapy hydration and/or rescue drugs. Errors were recorded and classified by error type, cause, severity, unit location, medication involved, and harm caused. RESULTS: A total of 205 observations were made and 23(13.6%) errors recorded, of which 6 were intercepted. No life-threatening adverse drug event was recorded. The most important risk factor predisposing to errors was admission to nonpediatric ward (P=0.004). Documentation errors and incorrect infusion time were the 2 most common errors, whereas the most frequent error node was administration error. Appropriate steps were taken to prevent their reoccurrence. CONCLUSIONS: This study helped provide important information about the rate and epidemiology of medication errors, emphasizing on the role of audit in enabling development of appropriate error-reducing strategies, particularly in the context of quality assurance in hospitals.
Authors: Katya Cuadros Carlesi; Kátia Grillo Padilha; Maria Cecília Toffoletto; Carlos Henriquez-Roldán; Monica Andrea Canales Juan Journal: Rev Lat Am Enfermagem Date: 2017-04-06