Error Number 50. Not being well informed about cancer drugs and their dosages

An oncologist wrote the following order for an elderly man who had terminal cancer:

After writing the order, the oncologist left the hospital and went on vacation.

The unit secretary transcribed the order on the patient's medication administration record. But instead of listing it in the "one time only" section, she mistakenly wrote it in the "scheduled medication" section. A nurse checked the transcription and signed it off as correct.

Ten days later, the oncologist returned from vacation. While reviewing the patient's chart, the oncologist discovered that the patient had received 10 doses of CCNU (lomustine), a potent antineoplastic drug, instead of the one dose he was supposed to receive. The doctor found that the patient had developed bone marrow suppressIOn.

Since nothing could be done to reverse the effects of the overdose, the patient died a week later of kidney failure.

Why did this error occur? Unfortunately, each health care professional who had a chance to correct the erroneously transcribed order failed to do so. Two pharmacists were responsible for filling the order. Even though they discussed the dosage, they didn't check it in a drug reference.

Three nurses administered the drug, but only one checked the dosage in a drug reference. Unfortunately, this nurse misread the manufacturer's recommendation to "give every 6 weeks." She thought it read "give for 6 weeks." No one checked the oncologist's progress notes, which did state his intentions for this patient: "Will try a dose of CCNU."

Because most cancer drugs are toxic, even in therapeutic doses, overdoses can be especially harmful to the patient. Therefore, all health care professionals must use particular caution when administering these drugs.

Many hospitals are preventing such errors by confining cancer chemotherapy to a designated nursing unit. This gives the staff a chance to learn specifically about cancer drugs and dosages. Both an oncology nurse clinician and a clinical oncology pharmacist may be available to teach the staff, review drug orders, and answer questions.

Whether or not the hospital where you work has such a policy, make sure you're well informed about each cancer drug and its dosage before you administer it to a patient. Follow these guidelines for safe administration:

• Look up the drug in a drug reference.
• Check the patient's chart for the protocol or progress notes, which should further describe the therapy.
• Ask the doctor to go over his orders with you so there can be no room for misinterpretation.
• Have another nurse check the drug against the order before you administer it.
• Don't give the drug until you're satisfied you know how to give it correctly.