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P03 An evaluation of medication errors in paediatric cytotoxic chemotherapy, prior to electronic prescribing implementation
  1. Hatton Jenni
  1. Nottingham Children’s Hospital


Aim To investigate the incidence and severity of errors in the prescribing and administration of paediatric cancer chemotherapy, in order to improve the safety of current practice and use as a comparison following the introduction of electronic prescribing.

Method In a children’s cancer Principal Treatment Centre, the following was reviewed:

  • Incident reports relating to cancer chemotherapy for the previous three years. The Trust’s incident reporting database was searched using location for each ward/out–patient area, as well as searching by keywords for ‘chemo’, ‘chemotherapy’ and individual drug names.

  • Interventions made by paediatric oncology pharmacists screening chemotherapy prescriptions for the most recent eight month period. These were recorded by the pharmacists directly onto a spreadsheet at the time of screening the prescription. All amendments/clarifications to prescriptions were asked to be recorded, regardless of whether they required the action of e.g. the prescriber.

Each report was categorised according to type and severity by a multi-disciplinary team comprising a senior nurse, paediatriconcology consultant and a senior paediatric oncology pharmacist. Activity was defined as the number of chemotherapy items manufactured for the children’s cancer wards.

Incidents and pharmacist interventions were categorised as follows:

  • Chemotherapy Medication (Incorrect drug, dose, durations or routes of administration)

  • Roadmap errors (Incorrect protocol selected or sequencing of cycles within a protocol)

  • Supportive care measures (Incorrect IV fluids or supportive medications)

  • Timing errors (incorrect day/time)

  • Pharmacy errors (dispensing or labelling)

  • Clerical errors (Incorrect identifying data e.g. patient number)

  • Communication/process errors (e.g. Failure to collect medication/expired chemotherapy)

  • Pharmaceutical (e.g. amending fluids to ensure stability)

  • No error – but clarification needed adding to prescription Harm was categorised using the American NCC MERP scale.1

Results Incident reports over the three year period were at rates of 0.37%, 0.48% and 0.43% respectively as a proportion of the number of items of chemotherapy manufactured.

Communication and pharmacy errors were the most common.

There is a trend towards an increasing rate of incidents with the potential to cause harm year on year.

Rates of pharmacy interventions were variable and difficult to analyse. The most common errors intercepted were chemotherapy and roadmap errors. There were a large number of uncategorised interventions, mostly relating to pharmaceutical manufacture.

Conclusion The incident report rates are comparable with those found in the literature.2

Undertaking this investigation raised awareness of medication safety within the paediatric oncology service.

Concurrent work looked at which errors would and would not be mitigated by the introduction of electronic prescribing. These data will be used as a comparison for studies once electronic prescribing is established.


  1. National Coordinating Council for Medication Error Reporting and Prevention. Index for Categorising Medication Errors2001.

  2. Watts RG, Parsons K. Chemotherapy medication errors in a paediatric cancer treatment centre: Prospective characterisation of error types and frequency and development of a quality improvement initiative to lower the error rate. Pediatr Blood Cancer2013;60:1320–4.

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