%0 Journal Article
%T Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study
%A Anthony C. Easty
%A Heather A. Logan
%A Melissa C. Kozak
%A Patricia L. Trbovich
%A Paul M. Koke
%A Rachel E. Gilbert
%A Roxanne B. Dobish
%A Venetia C. Bourrier
%A Vishal Kukreti
%J General Information | Journal of Oncology Practice
%D 2018
%R https://doi.org/10.1200/JOP.17.00007
%X INTRODUCTION Section: ChooseTop of pageAbstractINTRODUCTION <<METHODSRESULTSDISCUSSIONREFERENCES The past few decades have brought a growing awareness of the effect of human error on health care, including in oncology practice. Although several studies have established rates of error, or active failures, with chemotherapy,1-4 theorists such as Reason5 have highlighted the importance of studying working conditions so that the underlying potential human failures, or latent errors, can be remedied. For example, whereas an active failure would be the selection and use of the wrong drug during chemotherapy mixing, a latent error would be the storage of look-alike drugs beside each other. In 2014, members of our team published an observational study that described three types of previously unrecognized latent chemotherapy preparation errors in Canadian oncology pharmacies.6 The following potentially catastrophic compounding errors would not have been detectable if they occurred: For drugs that require reconstitution, the incorrect volume or type of diluent could be injected into a chemotherapy vial because quality checks of reconstitution were not in routine use and may not always be effective when they are used. The incorrect medication could be selected and drawn into a syringe but the correct vial shown to the pharmacist during their check because multiple drugs often were stored in proximity in the biologic safety cabinet (BSC). The wrong patient-specific drug label could be applied to a correctly mixed bag because labels often were not physically affixed to the bag in which the drugs were to be injected until after mixing was complete. Since, intravenous (IV) compounding safety has garnered increased attention as a result of some high-profile incidents,7,8 awareness efforts from the safety community,9-11 and increasingly stringent practice standards.12-16 Meanwhile, new research with more-sensitive error detection techniques than in past studies has continued to reinforce that error rates with manual IV compounding are unacceptably high.17-19 As did our original work, this study used human factors¨Cinformed observation and analysis to identify and describe latent errors. Whereas our previous study explored latent errors across the entire chemotherapy delivery pathway from ordering to administration, the goal of this study was to gain a deeper understanding of latent errors specific to manual chemotherapy compounding practices. METHODS Section: ChooseTop of pageAbstractINTRODUCTIONMETHODS <<RESULTSDISCUSSIONREFERENCES Field observations were conducted in
%U http://ascopubs.org/doi/full/10.1200/JOP.17.00007