looking through my work emails....

I get a newsletter from our pharmacy which in turn gets a newsletter from the Institute of Safe Medication Practices. With many of our drugs (not just chemo drugs) on backorder, I found this interesting and wanted to pass this along. I copied and pasted this from the newsletter regarding chemo drugs.

Chemotherapy
*Cytarabine dosing error occurred when a pharmacist used a mixing protocol applicable to the usual 500 mg vials (50 mg/mL, not available) but was actually using an alternative strength 1,000 mg vial
*Pre-diluted methotrexate was unavailable; a vial of dry powder was reconstituted incorrectly and the patient received less than the prescribed dose
*VinBLAStine shortage led to replacement with vinCRIStine for a patient with a hematologic disease, but a dosing error occurred when determining the dose for the alternative drug
*IV etoposide was converted to oral dosing, but the prescriber was not aware that the oral dose needed to be double the IV dose
*Physician prescribed the wrong dose when levoleucovorin was substituted for leucovorin
*Chemotherapy treatments delayed in a patient with a high potential for remission while attempting to find a source of the needed drug
*Switched cancer patients from leucovorin to levoleucovorin, from fluorouracil to capecitabine, and from asparaginase to pegasparagase, but the impact on overall survival and quality of life is undetermined
*Substituting XELODA (capecitabine) for leucovorin has resulted in serious gastrointestinal toxicity in many patients
*Chemoembolization was significantly delayed due to unavailability of mitomycin

There was a blurb in another newsletter of a physician transposing the height/weight of a patient in his computer and prescribing the wrong dose of a chemo drug. Before the next dose, the error was found, and his second and third doses were given correctly. The patient later died of a pulmonary emboli.

The event
Using an electronic prescribing system, a
physician entered a new order for panitumumab
(VECTIBIX) to be given intravenously
every 3 weeks to an adult patient
with metastatic colorectal cancer. The
usual dose of this drug is 6 mg/kg every 2
weeks, but the patient was enrolled in a
clinical trial with a protocol that called for
doses of 9 mg/kg every 3 weeks. While
entering the drug therapy into the
electronic prescribing system, the physician
inadvertently transposed the patient’s
height and weight: the height (cm) was
entered as the weight, and the weight (kg)
was entered as the height. As a result, the
patient received about 650 mg more
panitumumab than intended for the first
dose of therapy. The error was detected
before administration of the second dose,
and the patient received the second and
third dose of panitumumab as intended
according to the treatment protocol. After
the third dose, the patient was admitted to
the hospital with symptoms of pulmonary
embolism and died a few days later.
Panitumumab has been associated with
pulmonary embolism, but it is not known
if the initial erroneous dose of the medication
influenced the outcome in any way.
Contributing factors
With the assistance of the facility where the
event occurred, several factors contributing
to the error were identified.
Panitumumab and other monoclonal
antibodies are commonly dosed by
weight, whereas most chemotherapeutic
agents are typically dosed
according to body surface area (BSA)^2
In this case, the electronic prescribing
system automatically calculated the
patient’s BSA, which incorporates both
height and weight; the BSA was within
the expected normal range although it
was not needed to calculate the dose.
The patient was to receive a higher than
usual dose of panitumumab as
part of a clinical trial protocol (9 mg/kg
every 3 weeks, rather than the usual 6
mg/kg every 2 weeks). As a result, the
miscalculated dose, although high,
might have been attributed to the
clinical trial protocol and, therefore, not
investigated further.
The electronic prescribing system in
use at the facility alerts prescribers
when the entered height and/or weight
are out of range. However, it is hard to
distinguish between the height and
weight alerts, and the electronic
prescribing system does not require the
prescriber to acknowledge the alert or
enter a reason for overriding it.
Warnings about height and weight
being out of range appear only at the
point of order entry into the electronic
prescribing system. During order review,
pharmacy and nursing staff must
manually review patient characteristics
such as height and weight when
double-checking the prescribed dose.
In this case, the error was not detected
because only the BSA was viewed and
appeared to be within limits, not the
individual entries for height and weight.
Despite ongoing endorsement for using
the metric system in healthcare, many
practitioners continue to think in terms
of inches and pounds, not cm and kg.
Thus, the transposed height and weight
entries in this case were not immediately
correlated to a height of 3.5 feet
and a weight of nearly 400 pounds.

At our hospital, when I admit a patient to our unit, it asks for her weight in pounds. It then coverts it to Kg, but still keeps the lbs number visible for pharmacy and for nursing alike. It also does this for her height.

We all know that being our own advocate in our health care is essential. Please question your pharmacist or physician when getting your chemo. My chemo was mixed wrong twice during my FOLFOX treatments. I caught it both times and brought it to the nurses/oncs attention both times. Our pharmacists are not gods, but are mere humans--like us. They make mistakes, too. We, in the medical field strive for greatness when it comes to taking care of our patients. At least I try to.

Then there are the physicians who are so arrogant they can't believe they would ever make a mistake and there are those who are so ignorant they just don't know any better.
Arrogance and ignorance are a deadly combination, and some medical workers have both.

Please just be aware of what you're getting. I try to make sure my patients get what they're supposed to. I've caught our pharmacy putting in the wrong orders on the wrong patients many times. It's a check system. The computer actually caught me about six months ago trying to give one of my patients the wrong med. I was very glad that it caught my error before it reached the patient, but 20 some-years ago, there was no technological equipment and I made a couple of medication errors. I thank God none caused harm. So, as a patient, make sure you know what you're taking and WHY! Never be afraid to question your healthcare team. We're all human and make mistakes.