Investigation of parenteral drug administration errors in a medical oncology clinic

Abstract

Purpose: Parenteral drug administration errors (PDAEs) cause many medical and financial losses, due to the number of patients in medical oncology increases every year and the drugs administered are generally overpriced. The aim of the study is to detect the PDAEs that occur in an oncology clinic and contribute to taking the necessary measures for prevention.
Materials and methods: The all inpatient files who were previously diagnosed with cancer and treated in the medical oncology clinic in 2021 were reviewed retrospectively. Nurse observation and follow-up forms, near-miss event notification forms, physician orders and patient-based chemotherapy preparation unit reports were used to collect data. Descriptive statistics such as frequency, mean and percentage (%), and also chi-square test were used to analyze the variables.
Results: There were 301 patients over the age of 18 with complete files in the study group and 57 PDAEs were detected. It was calculated that the rate of PDAEs in the clinic was 18.9%. It was determined that the most common errors were “not following the administration duration (4.6%)”, “administering the drug at the wrong time (4.3%)”, and “skipping/not administering the drug dose (%3.7)” respectively.
Conclusion: In the study, it was determined a significant number of PDAEs occurred in the medical oncology clinic, but most were not written on the event reporting forms. In order to reduce the error rates, eliminating the pharmacological knowledge deficiencies of the health staff in the clinics, raising awareness about pharmacovigilance, paying more attention about patients’ training and revising the documentation system can make important contributions. Multicenter and large-scale studies are needed to determine the national or global strategies to be followed in order to prevent PDAEs in hospitals.

Keywords

• Drug administration errors
• medical oncology
• inpatient
• pharmacovigilance
• rational drug use

Bir tıbbi onkoloji kliniğindeki parenteral ilaç uygulama hatalarının incelenmesi

Öz

Amaç: Medikal onkolojide hasta sayılarının her geçen yıl artış göstermesi ve kullanılan ilaçların genel olarak pahalı ilaçlar olması nedeniyle parenteral ilaç uygulama hataları (PİUH) birçok tıbbi ve maddi kayıplara neden olmaktadır. Araştırmanın amacı, bir onkoloji kliniğinde meydana gelen PİUH’nı tespit ederek önlenmesi için gerekli tedbirlerin alınmasına katkıda bulunmaktır.
Gereç ve yöntem: Daha önce kanser tanısı konulmuş, tıbbi onkoloji servisinde tedavi gören 2021 yılına ait tüm yatan hastaların dosyaları retrospektif olarak incelendi. Verilerin toplanmasında hemşire gözlem ve takip formları, ramak kala olay bildirim formları, doktor orderları ve hasta bazlı kemoterapi hazırlama birimi raporlarından yararlanıldı. Değişkenlerin incelenmesinde frekans, ortalama ve yüzde (%) gibi tanımlayıcı istatistikler ile ki-kare testi kullanılmıştır.
Bulgular: Çalışma grubunda dosyaları eksiksiz olan 18 yaş üstü 301 hasta olduğu ve 57 adet PİUH yapıldığı belirlenmiştir. Klinikte PİUH oranının %18,9 olduğu hesaplanmıştır. En sık karşılaşılan hataların sırası ile infüzyon sürelerine uyulmaması (%4,6), ilacın yanlış zamanda verilmesi (%4,3) ve ilaç dozunun atlanması/verilmemesi (%3,7) olduğu belirlenmiştir.
Sonuç: Araştırmada tıbbi onkoloji kliniğinde PİUH’nın azımsanamayacak derecede fazla sayıda meydana geldiği ancak bunların büyük bir bölümünün olay bildirim formlarına yansımadığı belirlenmiştir. Hata oranlarının azaltılması amacıyla kliniklerde görevli sağlık personelinin farmakolojik bilgi eksikliklerinin giderilmesi, farmakovijilans konusunda farkındalığın sağlanması, hasta eğitimlerine daha fazla özen gösterilmesi ve dokümantasyon sisteminin revize edilmesi önemli katkılar sağlayabilir. Hastanelerde PİUH’nın önlenmesi için izlenecek ulusal ya da global çapta stratejilerin belirlenebilmesi amacıyla çok merkezli ve büyük ölçekli çalışmalara ihtiyaç bulunmaktadır. 

Anahtar Kelimeler

• İlaç uygulama hataları
• tıbbi onkoloji
• yatan hasta
• farmakovijilans
• akılcı ilaç kullanımı

Kaynakça

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