Investigation of parenteral drug administration errors in a medical oncology clinic/Bir tibbi onkoloji klinigindeki parenteral ilac uygulama hatalarinin incelenmesi

• Published in: Pamukkale Medical Journal Vol. 15; no. 4; p. 720
• Main Authors: Karakoc, Metin Deniz, Ozer, Ozden
• Format: Journal Article
• Language: English
• Published: Pamukkale University 01.10.2022
• Subjects: Analysis; Cancer; Chemotherapy; Health aspects; Hospitals; Investigations; Medication errors; Nurses; Toiletries industry
• ISSN: 1309-9833
• DOI: 10.31362/patd.1088164

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, nearmiss 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. Key words: Drug administration errors, medical oncology, inpatient, pharmacovigilance, rational drug use. Amac: Medikal onkolojide hasta sayilarinin her gecen yil artis gostermesi ve kullanilan ilaclarin genel olarak pahali ilaclar olmasi nedeniyle parenteral ilac uygulama hatalari (P?UH) bircok tibbi ve maddi kayiplara neden olmaktadir. Arastirmanin amaci, bir onkoloji kliniginde meydana gelen P?UH'ni tespit ederek onlenmesi icin gerekli tedbirlerin alinmasina katkida bulunmaktir. Gerec ve yontem: Daha once kanser tanisi konulmus, tibbi onkoloji servisinde tedavi goren 2021 yilina ait tum yatan hastalarin dosyalari retrospektif olarak incelendi. Verilerin toplanmasinda hemsire gozlem ve takip formlari, ramak kala olay bildirim formlari, doktor orderlari ve hasta bazli kemoterapi hazirlama birimi raporlarindan yararlanildi. Degiskenlerin incelenmesinde frekans, ortalama ve yuzde (%) gibi tanimlayici istatistikler ile ki-kare testi kullanilmistir. Bulgular: Calisma grubunda dosyalari eksiksiz olan 18 yas ustu 301 hasta oldugu ve 57 adet P?UH yapildigi belirlenmistir. Klinikte P?UH oraninin %18,9 oldugu hesaplanmistir. En sik karsilasilan hatalarin sirasi ile infuzyon surelerine uyulmamasi (%4,6), ilacin yanlis zamanda verilmesi (%4,3) ve ilac dozunun atlanmasi/ verilmemesi (%3,7) oldugu belirlenmistir. Sonuc: Arastirmada tibbi onkoloji kliniginde P?UH'nin azimsanamayacak derecede fazla sayida meydana geldigi ancak bunlarin buyuk bir bolumunun olay bildirim formlarina yansimadigi belirlenmistir. Hata oranlarinin azaltilmasi amaciyla kliniklerde gorevli saglik personelinin farmakolojik bilgi eksikliklerinin giderilmesi, farmakovijilans konusunda farkindaligin saglanmasi, hasta egitimlerine daha fazla ozen gosterilmesi ve dokumantasyon sisteminin revize edilmesi onemli katkilar saglayabilir. Hastanelerde P?UH'nin onlenmesi icin izlenecek ulusal ya da kuresel capta stratejilerin belirlenebilmesi amaciyla cok merkezli ve buyuk olcekli calismalara ihtiyac bulunmaktadir. Anahtar kelimeler: Ilac uygulama hatalari, tibbi onkoloji, yatan hasta, farmakovijilans, akilci ilac kullanimi.