Analysis of medication errors of cytotoxic drugs in pharmacy intravenous admixture service
10.3760/cma.j.cn114015-20200302-00195
- VernacularTitle:静脉用药调配中心细胞毒性药物用药错误发生情况分析
- Author:
Wensi ZHANG
1
;
Yanhua ZHANG
1
;
Xuemei LI
1
;
Jingxia HAN
1
;
Yi DING
1
Author Information
1. 北京大学肿瘤医院暨北京市肿瘤防治研究所药剂科，恶性肿瘤发病机制及转化研究教育部重点实验室，北京 100142
- Publication Type:Journal Article
- Keywords:
Medication errors;
Antineoplastic agents;
Patient safety;
Pharmacy intravenous admixture services
- From:
Adverse Drug Reactions Journal
2020;22(11):613-618
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To explore the occurrence of medication errors (MEs) involving cytotoxic drugs in pharmacy intravenous admixture service (PIVAS).Methods:All the prescriptions containing cytotoxic drugs from January 2016 to December 2019 in PIVAS in Peking University Cancer Hospital were collected using the hospital information system. ME records found by pharmacists during the prescription review were screened out (defined as prescription error) and "the medication error record book" was searched to screen out MEs in PIVAS (defined as admixture errors) in the same period. Descriptive analysis was conducted on the grade, classification, links in which the MEs occurred, people who triggered, ME content, and the involved cytotoxic drugs of these MEs. In addition, the MEs that were not found in PIVAS but passed to the next link were defined as out-door errors.Results:A total of 347 367 prescriptions involving cytotoxic drugs were received in PIVAS in our hospital during the study period, in which 1 080 MEs were found, and the incidence of ME was 0.31%. The 1 080 MEs were all grade B errors that did not cause patient harm, of which 841 (77.87%) were prescription errors and 239 (22.13%) were admixture errors. Five MEs were not intercepted and led to out-door errors and the incidence of out-door errors was 0.01‰(5/347 367). The top 5 ME contents were wrong solvent (63.15%, 682/1 080), incomplete prescription (11.67%, 126/1 080), wrong number (8.80%, 95/1 080), wrong dose (6.11%, 66/1 080), and wrong method in intravenous administration (4.35%, 47/1 080). A total of 32 cytotoxic drugs were involved in 1 080 MEs and the top 5 were paclitaxels (23.24%, 251/1 080), fluorouracil (12.59%, 136/1 080), doxorubicin (6.39%, 69/1 080), cisplatin (5.46%, 59/1 080), and etoposide (5.37%, 58/1 080).Conclusions:The incidence of ME was 0.31% in PIVAS in our hospital, all of which were grade B errors. The errors mainly were prescription errors, the main contents were wrong solvent, and the main drugs involved were paclitaxels, fluorouracil, doxorubicin, cisplatin, and etoposide.
