Root cause analysis of safety incidents in antineoplastic use in children.
Elizangela Domiciano Garcia Barreto, Valcieny Souza Sandes, Gustavo Cattelan Nobre and 3 others
PMID 39016429WHAT IT FOUND
Most chemotherapy safety incidents in children were prescription errors, especially wrong day or dose.
Active searching in 2020 found almost five times more incident reports than in 2019. One incident reached a patient as an overdose, but caused no harm.
Key findings
01Prescription incidents were the most common category, at 57% in 2019 and 65% in 2020.
02Active searching in 2020 found 34 incidents, compared with 7 reported in 2019, and reports were almost five times greater.
03Contributing factors included manual or altered prescriptions, interruptions, lack of electronic alerts, work overload, tiredness, and limited physical space.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
It was a single-case quality improvement study in one hospital, so the incident counts and causes may not apply to other units. Routine reporting likely undercounted incidents, because active searching found many more reports. The RCA group met only three times, so other causes or solutions may not have been explored. The study described incidents and contributing factors; it did not test whether the analysis reduced future errors. Only one incident reached a patient, so it cannot show how often medication incidents cause harm.
The easy way to misread this
Do not read the rise from 7 incidents in 2019 to 34 incidents in 2020 as evidence that safety worsened. The paper says active searching and incentives produced almost five times more reports, while routine reporting likely undercounted incidents.