LEADERSHIP COLUMN Medication errors and shift to a culture of patient safety and high reliability

摘要

M edication errors with antineoplastic drugs can be disastrous to patients due to the drugs’ high toxicity and limited therapeutic index. Cancer patients often require numerous complex and often toxic therapies for treatment, which requires careful coordination of care. In a study involving 6,607?antineoplastic prescriptions, the researchers found an error rate of 5.2%?(449). The highest errors were prescription errors?(91%), followed with pharmaceutical?(8%) and administration errors?(1%). The researchers estimated that 13.4% of these errors would have resulted in a patient injury, 2.6% in permanent damage, and 2.6% would have affected the prognosis of the cancer patient. Gandhi et?al.?(2005) found the chemotherapy error rate was 3% in 3,200 chemotherapy orders for adult and pediatric patients. In a study involving pediatric and adult oncology patients, the authors found chemotherapy errors were 0.3 to 5.8 per 100?visits?(Walsh et?al., 2009).