Pediatr Blood Cancer 2014;61:2218–2222
Medication Errors on Oral Chemotherapy in Children With Acute Lymphoblastic Leukemia in a Developing Country Sapna Oberoi,
MD, DM,
1
Amita Trehan,
MD,
Background. Medication errors occur universally. Inappropriate administration of chemotherapy drugs can have adverse effects in cancer patients. Our objective was to assess the rate and type of medication errors in children with acute lymphoblastic leukemia (ALL) receiving oral chemotherapy in outpatient setting. Procedure. Prescription and administration of oral chemotherapy drugs in children with ALL were evaluated prospectively to determine rate and type of medication errors. Errors were defined as prescription (physician) level or administration (patient) level errors. Results. Two hundred eighty-nine drugs were prescribed to 121 patients. Medication errors occurred in 36 (12.5%) prescriptions; 21(7.3%) were administration errors, 13 (4.5%) were prescribing errors, and two errors occurred at both levels. Mercaptopurine (6-MP) was significantly associated with higher rates of errors (Odds ratio [OR] ¼ 2.1, 95% CI [confidence interval] 1–4.1) whereas lapses
2
* and Ram Kumar Marwaha,
MD, MNAMS
2
were less with dexamethasone (OR ¼ 0.25, 95% CI 0.09–0.67). As a result of medication errors 28 (23.1%) patients received inappropriate doses. Twenty five (21%) patients received sub-optimal doses whereas three got higher doses of chemotherapy. On univariate analysis, socioeconomic status, education status of the caregiver, 6-MP and methotrexate were significantly associated with errors (P 0.05). On multivariate analysis, primary school education of the caregiver and prescription of methotrexate were independent predictors of errors. Conclusions. Medication errors affected nearly one fourth of the children receiving oral chemotherapy. Future studies are needed to look at effective interventions to avoid chemotherapy associated errors especially amongst the lower strata of society. Pediatr Blood Cancer 2014;61:2218–2222. # 2014 Wiley Periodicals, Inc.
Key words: acute lymphoblastic leukemia; chemotherapy; children; medication errors
INTRODUCTION Medication errors are well known to occur in the health care system [1]. The adverse effects of these errors could be detrimental in patients undergoing treatment for cancer [2–4]. Medication errors occurring both as an inpatient and outpatient have been described in children getting treatment for cancer [5–7]. These errors can stem from wrong prescription, dispensing, or administration of the chemotherapeutic drugs. Children on chemotherapy are particularly more vulnerable to this due to frequent changes in the dose of medications in adjustment to change in weight and height, complexity of the chemotherapy regimens, dependence on caregiver for the medications, and intricate weekly dosing due to unavailability of liquid medications [2,3,5,7]. Few studies in the past have looked in to medication errors among pediatric oncology patients. The reported error rates vary from 3% to 19% based on the setting [2–5,7]. However, all these studies have been conducted in countries with a high human development index (HDI); a composite measure of life expectancy, access to education and income levels, the world average being 0.695 [8]. The health care system in countries with low and medium HDI is less advanced [8]. India has a HDI of 0.558 and is ranked at a low 136 among 186 countries on its HDI. Outpatient chemotherapy becomes even more challenging in these low income countries due to high patient to doctor ratio, lack of dispensing pharmacist, lack of medical insurance, greater number of patients belonging to the low socioeconomic status, and communication barriers resulting from educational status of the caregivers [9]. The risk of potential adverse events occurring with over dosage of chemotherapeutic agents is immense. On the other hand, suboptimal doses of medications are detrimental to the cure of cancer [10–12]. The importance of maintenance chemotherapy and the role of adherence to it have been proven beyond doubt in children with acute lymphoblastic leukemia (ALL) [10,12]. We conducted this study to assess the frequency and nature of medication errors occurring in the C
2014 Wiley Periodicals, Inc. DOI 10.1002/pbc.25203 Published online 30 August 2014 in Wiley Online Library (wileyonlinelibrary.com).
outpatient setting in children on oral chemotherapy for treatment of ALL in our pediatric center.
METHODS This prospective cross sectional study was conducted over a period of three months (December 2010 to February 2011) in the pediatric oncology clinic of a tertiary care center in North India. Children aged
Medication Errors on Oral Chemotherapy in Children With Acute Lymphoblastic Leukemia in a Developing Country Sapna Oberoi,
MD, DM,
1
Amita Trehan,
MD,
Background. Medication errors occur universally. Inappropriate administration of chemotherapy drugs can have adverse effects in cancer patients. Our objective was to assess the rate and type of medication errors in children with acute lymphoblastic leukemia (ALL) receiving oral chemotherapy in outpatient setting. Procedure. Prescription and administration of oral chemotherapy drugs in children with ALL were evaluated prospectively to determine rate and type of medication errors. Errors were defined as prescription (physician) level or administration (patient) level errors. Results. Two hundred eighty-nine drugs were prescribed to 121 patients. Medication errors occurred in 36 (12.5%) prescriptions; 21(7.3%) were administration errors, 13 (4.5%) were prescribing errors, and two errors occurred at both levels. Mercaptopurine (6-MP) was significantly associated with higher rates of errors (Odds ratio [OR] ¼ 2.1, 95% CI [confidence interval] 1–4.1) whereas lapses
2
* and Ram Kumar Marwaha,
MD, MNAMS
2
were less with dexamethasone (OR ¼ 0.25, 95% CI 0.09–0.67). As a result of medication errors 28 (23.1%) patients received inappropriate doses. Twenty five (21%) patients received sub-optimal doses whereas three got higher doses of chemotherapy. On univariate analysis, socioeconomic status, education status of the caregiver, 6-MP and methotrexate were significantly associated with errors (P 0.05). On multivariate analysis, primary school education of the caregiver and prescription of methotrexate were independent predictors of errors. Conclusions. Medication errors affected nearly one fourth of the children receiving oral chemotherapy. Future studies are needed to look at effective interventions to avoid chemotherapy associated errors especially amongst the lower strata of society. Pediatr Blood Cancer 2014;61:2218–2222. # 2014 Wiley Periodicals, Inc.
Key words: acute lymphoblastic leukemia; chemotherapy; children; medication errors
INTRODUCTION Medication errors are well known to occur in the health care system [1]. The adverse effects of these errors could be detrimental in patients undergoing treatment for cancer [2–4]. Medication errors occurring both as an inpatient and outpatient have been described in children getting treatment for cancer [5–7]. These errors can stem from wrong prescription, dispensing, or administration of the chemotherapeutic drugs. Children on chemotherapy are particularly more vulnerable to this due to frequent changes in the dose of medications in adjustment to change in weight and height, complexity of the chemotherapy regimens, dependence on caregiver for the medications, and intricate weekly dosing due to unavailability of liquid medications [2,3,5,7]. Few studies in the past have looked in to medication errors among pediatric oncology patients. The reported error rates vary from 3% to 19% based on the setting [2–5,7]. However, all these studies have been conducted in countries with a high human development index (HDI); a composite measure of life expectancy, access to education and income levels, the world average being 0.695 [8]. The health care system in countries with low and medium HDI is less advanced [8]. India has a HDI of 0.558 and is ranked at a low 136 among 186 countries on its HDI. Outpatient chemotherapy becomes even more challenging in these low income countries due to high patient to doctor ratio, lack of dispensing pharmacist, lack of medical insurance, greater number of patients belonging to the low socioeconomic status, and communication barriers resulting from educational status of the caregivers [9]. The risk of potential adverse events occurring with over dosage of chemotherapeutic agents is immense. On the other hand, suboptimal doses of medications are detrimental to the cure of cancer [10–12]. The importance of maintenance chemotherapy and the role of adherence to it have been proven beyond doubt in children with acute lymphoblastic leukemia (ALL) [10,12]. We conducted this study to assess the frequency and nature of medication errors occurring in the C
2014 Wiley Periodicals, Inc. DOI 10.1002/pbc.25203 Published online 30 August 2014 in Wiley Online Library (wileyonlinelibrary.com).
outpatient setting in children on oral chemotherapy for treatment of ALL in our pediatric center.
METHODS This prospective cross sectional study was conducted over a period of three months (December 2010 to February 2011) in the pediatric oncology clinic of a tertiary care center in North India. Children aged
