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. 2012 Sep;21(5):606-13.
doi: 10.1111/j.1365-2354.2012.01331.x. Epub 2012 Feb 16.

Characteristics of medication errors with parenteral cytotoxic drugs

A Fyhr  1 , R Akselsson
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Free PMC article

Characteristics of medication errors with parenteral cytotoxic drugs

A Fyhr et al. Eur J Cancer Care (Engl). 2012 Sep.
Free PMC article

Abstract

Errors involving cytotoxic drugs have the potential of being fatal and should therefore be prevented. The objective of this article is to identify the characteristics of medication errors involving parenteral cytotoxic drugs in Sweden. A total of 60 cases reported to the national error reporting systems from 1996 to 2008 were reviewed. Classification was made to identify cytotoxic drugs involved, type of error, where the error occurred, error detection mechanism, and consequences for the patient. The most commonly involved cytotoxic drugs were fluorouracil, carboplatin, cytarabine and doxorubicin. The platinum-containing drugs often caused serious consequences for the patients. The most common error type were too high doses (45%) followed by wrong drug (30%). Twenty-five of the medication errors (42%) occurred when doctors were prescribing. All of the preparations were delivered to the patient causing temporary or life-threatening harm. Another 25 of the medication errors (42%) started with preparation at the pharmacies. The remaining 10 medication errors (16%) were due to errors during preparation by nurses (5/60) and administration by nurses to the wrong patient (5/60). It is of utmost importance to minimise the potential for errors in the prescribing stage. The identification of drugs and patients should also be improved.

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Figures

Figure 1
Figure 1
Origin of reports. A total of 56 reports were filed according to lex Maria. Nine of these were reported to HSAN from National Board of Health and Welfare, together with four reports from relatives a total of 13 were investigated by HSAN. HSAN, Medical Responsibility Board; ME, medication error.
Figure 2
Figure 2
Start and fate of the investigated medication errors (MEs). It shows if the drugs were delivered to the patient or if the error was intercepted. The left column lists who discovered the ME or if it was discovered due to an adverse reaction (AR). The right column lists the consequences for the patients. *One ME involved two patients.
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