A medication error associated with chemotherapy can be lethal for the patient. Rinke et al summarized medication errors reported to a national database (USP MEDMARX). The use of a centralized error reporting database can be helpful in reducing future errors.

Situation: pediatric chemotherapy


Error types:

(1) improper dosing

(2) error in timing of dose administration (wrong time)

(3) error of omission

(4) wrong route and/or wrong administration technique

(5) prescribing error (error in written order)

(6) improper preparation (drug preparation error)

(7) extra dose

(8) wrong drug or wrong dosing form

(9) wrong patient

(10) expired or deteriorated product


Common underlying causes for the errors:

(1) deficit in performance

(2) defect in equipment or drug delivery device

(3) error in communication

(4) knowledge deficit

(5) human-related computer error

(6) transcription error

(7) miscalculation of dose

(8) brand name similarities

(9) high workload or stress

(10) labelling errors


Risk factors for serious errors:

(1) chemotherapy in a community hospital

(2) lack of system safeguards

(3) high workload

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