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Medication Errors Common in Kids' Leukemia Treatment
by: Steven Reinberg

Ten percent of children with a once-deadly childhood cancer do not get the correct chemotherapy regime because of medication errors, new research contends.

Fortunately, most of the errors, either from parents administering oral medicine at home or from incorrect prescriptions, do no permanent harm, University of Washington researchers found.

According to the report in the Aug. 14 online edition of Cancer, 9.9 percent of the oral chemotherapy medications were prescribed or given incorrectly to children with acute lymphoblastic leukemia (ALL).

Medical errors in the United States cause up to 98,000 hospital deaths per year and are thought to be common among outpatients. But they have not been well studied, particularly in children.

To find that out, "we did a study to see how often parents with ALL will give the medicine as prescribed and how often we prescribe the medication as we intend to," said Dr. James A. Taylor, a professor of pediatrics at the University of Washington and Children's Hospital and Regional Medical Center.

Taylor's team looked at the rate and types of medications errors that occurred for 69 children receiving outpatient chemotherapy regimen for ALL. "We found in 10 percent of the medications administered, there was a error in what was intended and what was actually administered to the child," Taylor said.

Of the 17 total errors, 12 were the result of how the medications were administered, and five were caused by prescribing errors -- incorrect dosages. Taylor's group found no dispensing errors by a pharmacy.

Four of the errors were potentially significant. Three children failed to receive medications at the appropriate time, increasing the risk of relapse. One received an overdose of medication, and so was at risk for a life-threatening infection, the researchers reported.

Parents said the protocols were explained very well to them by doctors, nurses and pharmacists. In addition, education level or ethnic background didn't make a difference in understanding the instructions, Taylor said.

Taylor doesn't blame the parents for the errors, but rather the protocols, which are complicated and hard to follow. "These are very complicated regimens," he said. "It's really hard to give these medications as we intend."

To reduce errors, Taylor would like to see the regimens made less complicated. "People, when they design a protocol for treatment of cancer or any disease, shouldn't make it so complicated that it is going to be prone to errors," he said. "By simplifying the protocol, you might end up with better outcomes."

One of the ways of eliminating error is using electronic prescribing systems to eliminate human error, said Dr. Lydia Gonzalez-Ryan, clinical director of the Aflac Cancer Center and Blood Disorders Center of Children's Healthcare of Atlanta. "There needs to be standardized practices," she added. "We need to get into preprinted orders that set up quality control."

For parents, Gonzalez-Ryan believes that electronic prescribing orders with a printed report and dosing roadmaps will help eliminate errors. Doctors also need to be diligent, she said. "Doctors need to take good histories," she said.

Doctors should have parents bring in the medication to check what has been given, and they should have the parents demonstrate how they give the medications, she added.

Another expert agreed that complicated regimens are at the root of the problem. But doctors need to be clear in explaining the regimen to patients.

"We need to find ways to reduce errors from patients not understanding complicated regimens that are necessary to treat this disease," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society.

"We need to make sure that our instructions to our patients are culturally appropriate," Lichtenfeld added. "We need to make the effort to be sure that patients understand what we are saying to them."

Another expert thinks that because these errors don't affect long-term outcomes, the problem is more a theoretical than a real problem.

"I think the problem is less serious than they make it out to be," said Dr. Daniel S. Wechsler, an associate professor of pediatrics and communicable diseases at the University of Michigan Medical School. "Parents doing this are motivated and are invested in doing the right thing for their kids."

Wechsler did note, however, that to avoid errors, doctors should educate parents in how to follow the regimen and mandate that prescriptions be filled at the hospital pharmacy to insure quality. In addition, they should be careful to do follow-ups with parents during monthly patient visits.

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