Original Research
Tuesday, November 14, 2023
08:30 AM–10:00 AM
Abstract
Introduction:
Medication errors are preventable events that may lead to inappropriate medication use or patient harm. Errors involving controlled drugs (CDs) are of concern as they have potential for addiction and overdose. Oncology patients often have higher utilization rates of CDs and have potential for higher rates of related medication errors.
Research Question or Hypothesis:
The purpose of this drug audit was to determine the existing trends in CD medication errors within an oncology specialty center.
Study Design:
A retrospective drug audit of medication safety reports from a large oncology specialty center in London, England.
Methods:
Safety reports were reviewed from January 2020 - December 2022 if they involved a CD from the oncology unit. Data collected included incident description, ward location, medication error category, incident harm level, action taken by incident manager, and drug administered. Ethics were not required.
Results:
There were 164 medication safety reports that met inclusion criteria. The majority involved oxycodone or morphine (79%), while zero resulted in patient harm. The most frequent CD errors were in administration (45%); the wrong drug, dose, or dosage form was administered for 47% of those. The next most frequently reported CD errors were in prescribing (14%), drug storage (12%), poor documentation (10%), and dispensing (10%). In 2022, agency nurses accounted for ~17% of administration errors and 10% of reported errors involved a dose miscalculation. Compared to the two previous years, 2022 experienced more incidents of patients receiving expired medications (n=5 vs. n=0).
Conclusion:
While no harm resulted from the errors, this audit revealed opportunities for process improvement and education to further optimize the use of CDs for oncology patients. Pharmacy can assist nursing through diligent expired medication evaluation, removing medications from cupboards for discharged patients, and supporting competency training on medication calculations and nurse-nurse CD checking to help reduce medication administration errors.
Presenting Author
Ellen Schellhase PharmDAuthors
Rakesh Mattu MPharm
St. Bartholomew's Hospital
Monica L. Miller PharmD, MS
Purdue University College of Pharmacy
Nina Teo Pharm.D.
Purdue University College of Pharmacy