Risks in the chemotherapy process and possibilities for improvement

Abstract: Medications are of considerable help if healthcare providers are able to administer them to patients safely and appropriately. The medication use process is complex and a team of professionals – doctors, nurses, and pharmacists – work together with the patient for optimal treatment effect. The process involves many sub-processes and in every step there is a possibility for an error. Cytotoxic drugs have high toxicity and a narrow therapeutic index, which means that there is little difference between a lethal and therapeutic dose. The use of such drugs may entail great risks for the patient. The general aim of the research presented in this thesis is to identify these risks and to identify actions and strategies for improving safety in the chemotherapy process. The research focuses on errors in the medication use process of parenteral cytotoxic drugs and how to prevent them. The main objectives are: o To proactively disclose system weaknesses in the process of prescribing and administering cytotoxic drugs in order to suggest interventions. o To identify the characteristics of the medication errors involving cytotoxic drugs in Sweden in order to gain increased knowledge about them. Two approaches have been applied: a proactive one using the disturbance effect barrier (DEB) method, and a retrospective one using a qualitative analysis of the data. The proactive method revealed system weaknesses mainly at the stage of prescribing and the medication use process was found to involve great risks for the patient. In the retrospective analysis, the most commonly involved drug was fluorouracil and the platinum containing drugs were the ones that often caused serious consequences for the patients. The most common error types were too high doses and use of the wrong drug. Fully 40% of the errors occurred at the prescribing and transcribing stage. All of these were delivered to the patient causing temporary or life-threatening harm. Fully 40% of the errors occurred at the preparation stage and were made by pharmacists. The rest of the errors occurred during preparation or administration by nurses. The stage of prescribing by doctors was identified as a major risk. The most commonly identified error types were wrong dose, drug or patient. This indicates that there are possibilities for improvements, such as by using computerised prescriber order entry (CPOE) systems and bar coding for identification of drug and patient. Other strategies for improvement of the chemotherapy process have been suggested in the literature. Among these are standardisation of prescribing vocabulary, multidisciplinary co-operation, working with pharmaceutical manufacturers, and education of the patients. As described in this thesis, the chemotherapy process is complex and involves a great deal of risks for the patients. There is great awareness of the risks and there are many suggestions for actions and strategies for improvements. Some of hese needs to be further evaluated and implemented for better safety for the patients.