GRP-094 Improvement of the Clinically Relevant Safety of Chemotherapy by the Involvement of a Clinical Pharmacist

Background To avoid medical errors and thus to improve the safety and quality of cancer treatment in our institution, all chemotherapy prescriptions are critically checked by a clinical pharmacist. Prescription errors are communicated immediately to the attending physician and corrected prior to the preparation and administration of the drugs. Purpose To compile error statistics and to assess the potential severity of errors in chemotherapy prescriptions, we retrospectively analysed and evaluated prescription errors in order to improve the safety of treatment. Materials and Methods 42624 paper written (no CPOE) chemotherapy prescriptions (containing 86101 prescriptions for medicines) from 19 departments of the University Hospital of RWTH Aachen between 2004 and 2009 were analysed retrospectively by the hospital pharmacy. The most important criteria for analysis were wrong patient, wrong drug, missing drug, wrong dose, wrong application day and wrong protocol. The clinical relevance of the medical errors detected was assessed independently by four oncologists and two clinical pharmacists using the criteria of Small et al , [1]. Results In total, 696 medicines errors were detected in 373 prescriptions during the routine verification by the pharmacist. By far the most abundant errors (92.4% of the total) were related to the dose. Of the 373 prescriptions the team reviewed 20% of the errors as minor, 50% as significant, 25% as severe and 5% as potentially fatal. Potentially fatal errors were detected in regard to overdoses and once to the prescription of the wrong drug. Conclusions Our results clearly show the relevance of clinical pharmacists being part of the therapeutic team to reduce medicines errors and to prevent any patient harm. Reference Small MD, Barrett A, Price GM. The impact of computerized prescribing on error rate in a department of Oncology/Hematology. J Oncol Pharm Pract 2008;14:181–7. No conflict of interest.