~Dennis Morgan, MD
Chemotherapy is one of the miracles of modern medicine. It is also the proverbial two-edged sword — curative or deadly. Doses, schedules and routes are carefully explored in clinical trials and guidelines published. But the actual administration is very complex and the margin for error very small. Despite abundant literature on how to reduce errors, dangers lurk within every infusion center. I recount here some experiences intended as an exercise in mindfulness — a reminder to learn and re-learn the principles of safe administration.
When I was a resident physician I was called one evening at midnight to administer a dose of vincristine. I met the nurse in the med room as she was loading a syringe. Handing it to me, she complained how cumbersome it was to draw up all ten vials that the pharmacy sent up. Some readers will gasp at this point. Vincristine comes in 2 mg vials. I was just handed 20 mg — a potentially fatal dose. The decimal point had not transferred to the carbon copy of the order.
The transcription error was caught because I had a pattern recognition for this drug. I knew the dose formula (1.4 mg/m2 — max 2 mg) and that it came in 2 mg vials. Early on in my residency I had taken an interest in oncology and was possibly the only house officer in that thousand bed hospital who knew instinctively that ten vials is a life-threatening dose. (Vincristine later became notorious for death due to inadvertent intrathecal administration).
This concept of a pattern recognition for the template of any given treatment shaped my habits in practice. I kept my repertoire of regimens as small as possible such that my staff and I were intimately familiar with each one. However some regimens are unavoidably complex. Experimental ones are fraught with peril since so few are familiar with the template. So it was in the notorious cases of a fatal overdose at a revered teaching hospital in Boston when a patient, a well-known health care reporter, died from an overdose due to misinterpretation of an order: 4 grams of cytoxan was given not over four days, but each day(1). The error was not recognized as a deviation by those downstream in the chain of treatment — it was masked by the eccentricity that attends experimental regimens.
There are plenty of cases where the wrong drug was given due to the problem of look-alike, sound-alike drugs (LASA)(2). As a fellow I was privy to a fatal case of a nursing home patient given daily Uracil mustard instead of the bladder analgesic Urised. There are many problematic pairs (e.g. vincristine — vinblastine)(). Precautions have included changing names (mithramycin was changed to plicamycin to distinguish it from mitomycin), the use of TALL MAN notation (vinCRIStine — vinBLAStine)(3), and computerized order entry (CPOE)(4). Entire drug regimens can suffer from this type of confusion. We had occasion to round with a nurse who had co-authored a well-known handbook on chemotherapy regimens. I declared I wanted to treat a patient with “COP-”. She astutely pinned me down: did I mean to give COPP or COP (the later not to be confused with CVP — same drugs, different dose).
Returning to the dose issue, I became meticulous about accuracy. My policy was at least two qualified people doing calculations at least twice each. Nonetheless I once ordered a dose of bleomycin much bigger than indicated. I had referenced a handbook in common use — but there was a typographical error. The fault was a failure of pattern recognition on my part, for the first cycle anyway.
That it will be the intended patient who gets the treatment should not to be taken for granted — identity checks are crucial. Consider two extensions of the concept of “the right patient”. One is having the right diagnosis. When I was interning in pathology we encountered a case of a revised diagnosis. A medicine resident had received several months of chemotherapy for osteogenic sarcoma. The new chief of pathology recognized the true diagnosis — benign myositis ossificans. The other extension to ‘right patient’ is the ‘ready patient’. I suspect every oncologist has regretted at least once not having the chem profile or blood counts before the drug was given.
Aside from the issue of skill set, the following illustrates the value of the patient as a team member in reducing errors. I was as an expert witness in a case of severe extravasation. A physician had substituted on a weekend for the oncology nurse. While the doctor pushed on the syringe of mitomycin the patient said his arm hurt — but it never hurt before, when his nurse gave his medication from a hanging bag. The doctor persisted and the patient ended up with a hole in his arm. Fortunately, there is now a trend to actively recruit patients in the process of trapping errors(5).
A recent study in a community outpatient infusion center concluded “The incidence of errors capable of causing harm was reduced from 4.2% with handwritten orders to 1.5% with preprinted orders … to 0.1% with CPOE”(4). I suspect many infusion centers are not doing as well. Constant vigilance is required to reduce errors and even improve on a 0.1% rate of harm, including death. Remember if it happens to your patient it is 100% for them. The essential principles and procedures are delineated in the ASCO/ONS guidelines(6) and in a comprehensive handbook by the Director of Pharmacy at Fox Chase Cancer Center(7), amongst many others(8). Monitoring outpatient use of oral chemotherapy is a special challenge.
To engrain in them the habit of safety every fellow should ‘push chemo’ as part of their training. They should at least once experience their mind second-guessing each calculation and their eyes second-guessing the hands as they dilute and draw up a measure of drug with the power to cure or kill. The sensation of holding a two-edge sword by the blade should follow them through the years of wielding a prescription pen.
What experiences have informed your own approach to chemotherapy safety?
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Bio
Dennis Morgan, MD is Assistant Clinical Professor University of Connecticut Health Center, Emeritus Staff Johnson Memorial Hospital and Medical Center Stafford CT and Past President Connecticut Oncology Association as well as Past Medical Director Phoenix Community Cancer Center, Enfield CT
References
(1) Betsy Lehman Center for Patient Safety and Medical Error Reduction
http://www.mass.gov/chia/consumer/betsy-lehman-…
(2) Look-alike, sound-alike drugs in oncology. Kovocic L, Chambers C. J Oncol Pharm Pract. 2011 Jun;17(2):104-18.
http://opp.sagepub.com/content/17/2/104.abstract
(3) Application of TALLman Lettering for Drugs Used in Oncology. ISMP Canada Safety Bulletin. Volume 10, Number 8 November 11, 2010.
http://www.ismp-canada.org/download/safetyBulle…
(4) Reduction in Chemotherapy Order Errors With Computerized Physician Order Entry. Meisenberg BR et al. JOP January 2014 vol. 10 no. 1 e5-e9.
http://jop.ascopubs.org/content/10/1/e5.abstract
(5) Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature. Schwappach DLB, Wernli M. (2010) European Journal of Cancer Care 19, 285–292.
http://onlinelibrary.wiley.com/doi/10.1111/j.13…
(6) 2013 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards Including Standards for the Safe Administration and Management of Oral Chemotherapy. Neuss MN et al. J Oncol Pract. 2013 Mar;9(2 Suppl):5s-13s.
http://www.instituteforquality.org/sites/instit…
(7) Guide To The Prevention Of Chemotherapy Medication Errors, 2nd Edition. Kloth DD. McMahon Publishing, Abraxis BioScience. 2010.
http://www.clinicaloncology.com/download/pg1012…
(8) Preventing Medication Errors in Cancer Chemotherapy. (Textbook Chapter 16).Learning Aids: Medication Errors, 2nd Edition. Cohen MR, ed. [See Lecture 6].
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