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Analysis of Home Medication Use for Leukemia Outpatients Reveals Medication Errors 10% of the Time

August 14, 2006

A study conducted at Children’s Hospital and Regional Medical Center identified that 10 percent of outpatient children with acute lymphoblastic leukemia (ALL) did not receive their prescribed dose of chemotherapy agent.

A study conducted at Children’s Hospital and Regional Medical Center identified that 10% of outpatient children with acute lymphoblastic leukemia (ALL) did not receive their prescribed dose of chemotherapy agent.

Published in the September 15, 2006 issue of Cancer, the study reveals that 10% of chemotherapeutic medications were prescribed or administered incorrectly to outpatients.

In the U.S. medical errors cause up to 98,000 hospital deaths per year. Medication errors in the outpatient setting have been thought to be some of the most common medical errors, but they are not well-studied in pediatric health care settings.

These mistakes can occur in prescribing by physicians, during interpretation and processing by pharmacists, and when they are administered at home by patients or caregivers.

“For the last few years we have been intensely involved in standardizing our processes to reduce all medical errors including medications — all in an effort to improve patient safety,” said Dr. Richard Molteni, medical director at Children’s Hospital.

“We chose to look at error rates in cancer medications given at home as part of our ongoing self-evaluation and self-improvement process and as a reflection of the potential seriousness of incorrect administration of these toxic agents,” said Molteni.

This study is the first of its kind to measure the medication error rate for oral chemotherapy in children.
~ Dr. Rich Molteni

“This study is the first of its kind to measure and publish the medication error rate for oral chemotherapy in children.”

“Children with cancer receive extremely toxic drugs, and medication protocols for these patients tend to be very complicated,” said Dr. James Taylor, lead researcher on the study and a professor of pediatrics at the University of Washington School of Medicine and researcher at Children’s Hospital.

“We wanted to see if the medicine was being prescribed and administered as intended.”

The study systematically reviewed the prescribing, dispensing and parental administration of medications for ALL to determine the rate and types of medication errors occurring in these patients.

The research team used a conservative definition of error to include more than a 10% difference between the planned and administered dose of a medication.

Researchers found no errors were made in dispensing the medications by pharmacists.

Approximately 70% of errors were due to parental administration of medications at home. Most of the errors occurred with steroid medications rather than toxic chemotherapeutic agents.

One or more errors were identified in 17 of 172 chemotherapeutic medications and impacted 13 of 69 patients. Of the medication errors, 12 were attributed to medication administration and five were attributed to prescription errors.

“The findings also suggested that parents have difficulty administering the complicated ALL medication,” said Molteni.

“These results are helping us to develop new systems, such as prescribing medication electronically as opposed to hand-written, and simplifying at-home medication directions for patients and parents.”

“By publishing these results we hope to establish a baseline medication error rate against which other institutions can compare their own medication safety systems and encourage additional research to improve chemotherapy administration,” said Molteni.

About Seattle Children’s

Consistently ranked as one of the best children’s hospitals in the country by U.S. News & World Report, Seattle Children’s serves as the pediatric and adolescent academic medical referral center for the largest landmass of any children’s hospital in the country (Washington, Alaska, Montana and Idaho). For more than 100 years, Seattle Children’s has been delivering superior patient care while advancing new treatments through pediatric research. Seattle Children’s serves as the primary teaching, clinical and research site for the Department of Pediatrics at the University of Washington School of Medicine. The hospital works in partnership with Seattle Children’s Research Institute and Seattle Children’s Hospital Foundation. For more information, visit or follow us on Twitter or Facebook.

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