Report Describes Chemotherapy Errors in Pediatric Patients

Kate Traynor

The vast majority of medication errors in children receiving chemotherapy reach the patient and occur during the administration of the drug, according to an analysis in the journal Cancer.

According to the report, which was released online last week, 85% of 310 pediatric chemotherapy medication errors identified in the United States Pharmacopeia (USP) Medmarx database during 1999–2004 reached the patient. In 49 of these cases, the patient required additional monitoring or drug intervention as a result of the error. Five of the errors resulted in both patient harm and a need for additional hospitalization or treatment.

Nearly half of all errors occurred during administration of the chemotherapy, 30% were attributed to the dispensing step, and 10% were classified as prescribing errors. Methotrexate was the agent cited in 15.3% of all pediatric medication errors, followed by cytarabine (12.1%), etoposide (8.3%), and doxorubicin (6.2%).

The study was conducted by researchers at the Johns Hopkins University and USP who queried the Medmarx database for pediatric medication errors. Of the nearly 30,000 errors involving patients under 18 years of age documented in the voluntary reporting system during the study period, the authors determined that 310 involved chemotherapeutic agents as defined in ASHP's American Hospital Formulary Service Drug Information reference.

These 310 errors took place at 69 U.S. health care facilities. According to the report, about 54% of the errors occurred at general community hospitals, 26% at university hospitals, 9% at outpatient treatment facilities, and 6% at specialty or children's hospitals.

Errors were most common in large inpatient facilities with 24-hour pharmacy support that treated a high number of patients than in smaller institutions with a lower patient census and limited pharmacist availability, the report stated. This finding was attributed to "greater volumes of oncology patients and more internal resources devoted to quality and error reporting" at these larger institutions.

According to the report, errors that occurred in the outpatient setting differed from those occurring in inpatient facilities. For example, administration errors accounted for half of all pediatric chemotherapy errors in inpatient facilities, compared with 42% at outpatient centers.

Nearly a third of all errors in the outpatient setting involved medication administration, but this type of error represented less than a quarter of all inpatient errors.

Although methotrexate topped the list of error-prone medications at both inpatient and outpatient facilities, there was variation between the settings with respect to other medications. After methotrexate, errors at inpatient facilities most frequently involved cytarabine, followed by doxorubicin, cyclophosphamide, and etoposide. In the outpatient setting, tretinoin, vincristine, asparaginase, and cyclophosphamide were the most commonly cited agents after methotrexate that were associated with errors.

The authors stated that their findings point to "clear areas for intensive patient safety research and development of targeted interventions" to improve drug safety in children being treated for cancer.

In particular, the report's authors regard medication-administration errors as a weak link in the drug-delivery system. The report states that pediatric hospitals should focus their safeguards to prevent administration errors for high-risk medications.

The report states that although computerized prescriber order-entry (CPOE) systems can limit prescribing errors, the technology is not suitable for reducing most other types of medication errors. But according to the report, CPOE systems perform less well for managing cancer treatments than for other types of medications and may not be very effective in the pediatric setting.

The authors stated that they believe their study is among the first of its kind and described their findings as a robust and useful snapshot of error trends that is worthy of further study.