Most Errors in Pediatric Chemo Make It to Patients

At the University of California, San Francisco, for instance, a computer system is used to calculate dose based on a patient's height and weight for a particular protocol and then produce appropriate electronic orders, as Dr. Katherine Matthay, chief of pediatric hematology-oncology at the UCSF Children's Hospital , explained. These orders are then checked by a nurse practitioner, an oncologist, and a pharmacist, checked again as the medicine is prepared, and yet again by the nurse who actually administers the drug.

"Despite this, occasionally errors are made in timing or due to faulty equipment or human error as noted in the article," Matthay said.

Miller stressed that this study in no way reports the actual rate of chemotherapy errors. To calculate that, she would need to know the total number of chemotherapy doses administered, which she does not have. In addition, MEDMARX is a voluntary database, and some errors undoubtedly go unreported. Indeed, that 85 percent of the reports cited in this study reach the patient could well be due to the fact that hospitals are more likely to report incidents that reach patients than those that are caught in time, she said.

Yet Miller expressed the hope that this study could lead to the development of what she called "targeted interventions" -- specific systems that can lower the likelihood of medication errors.

"It is impossible to be vigilant on everything, to never make an error, never be late. It's impossible. So, our struggle is to introduce something to make it more error-free," she said, citing as examples anything from new computer software, to enhancements in teamwork between the pharmacist, nurse, and physician, to standardizing protocols for administration of a particular drug.

Another expert called chemotherapy error monitoring "a huge issue."

Sarah Scarpace, a pediatric clinical pharmacist at UCSF Children's Hospital, said staff often have to contend with an additional level of confusion in administering chemo -- the fact that protocols sometimes differ in how they number their days. For example, one protocol may begin on "day 0" while another begins on "day 1," and staff can get confused -- the drug a patient gets on day 1; is that really their first day or their second?

Scarpace suggests standardizing the numbering of days in protocols and using barcoding technology to ensure the correct drug goes to the correct patient. "Certainly the barcoding thing may help to ensure you get the right drug to the right person at the right time," she said.

And one more thing: "Everyone should take a 'time out' to verify this is the right thing [drug]," she said. A "time out" is that moment when everyone steps back and makes sure the correct drug is being given at the right time, dose, to the right patient, Scarpace explained.

Parents can be key players in maintaining safety, too, Miller added. She advised parents to be active participants in their children's care. "Question each dose. Be empowered. Know what's going on. Know the drugs, doses, times, and routes, so when the nurse comes in to administer the drug, you know it is right, and you can help troubleshoot," she said.

More information

For more on dealing with chemotherapy, visit the National Cancer Institute.

SOURCES: Marlene Miller, M.D., associate professor, pediatrics, Johns Hopkins School of Medicine, Baltimore; Katherine K. Matthay, M.D., professor, pediatrics and chief, pediatric hematology-oncology, University of California, San Francisco, Children's Hospital; Sarah Scarpace, PharmD,pediatric clinical pharmacist,UCSF Children's Hospital; May 25, 2007, online edition,Cancer