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How you can help to ensure your safety when receiving cancer treatments

The following is modified from an article that was originally published by Hedy Cohen, RN (ISMP Vice President) and Jennifer Cohen, RN, (Oncology Nurse, University of Pennsylvania, Philadelphia, PA) in Coping magazine (September/October 1998).

Is that medication really yours?

Receiving cancer treatment, including chemotherapy, can be a very frightening experience for patients. It may feel as if you are placing your life completely in the hands of your doctors and nurses. In a very real sense you are, especially if you are unfamiliar with the medications you are receiving. For instance, did a nurse ever hand you a cup full of medications and say, "here are your morning medicines"? Are you "guilty" of accepting those medications without knowing their names? Have you ever looked up at your intravenous medication and see fluid in the container but you do not know what it is or how long it should infuse? These scenarios are true for some patients because they have complete trust in their health care providers, which allows them to feel safe. However, as important as trust is, blind trust is not enough to safeguard you against a medication error. It is very important for all patients to realize that nurses and doctors are human and despite the many check systems in place it's still possible for an error to happen.

One mistake by your health care provider could mean a tragic result for you. Although extremely rare, newspapers and magazines occasionally cover stories about tragic medication errors involving cancer patients. Naturally, as a patient or actively participating family member, you want to protect yourself or your loved one from the possibility of such a situation. Many doctors and nurses realize that their best ally in preventing a medication error tragedy is you! So here are some tips for avoiding chemotherapy medication errors.

The most important step for your protection is to educate yourself about your condition and treatment. Most patients probably have done this in one way or another when initially diagnosed. However, educating yourself should not end with only knowing about your disease and treatment options. It must be much more far-reaching than that.

Education begins by listening carefully and writing down the name and dose of every medication that your doctor outlines in your treatment plan. Otherwise, it is nearly impossible to remember all of this information. It is essential that you maintain complete and up-to date records of all of your medication names (including brand and generic name, such as Tylenol/acetaminophen). Know why you are taking them, their doses and possible side effects. Also, most cancer nurses will provide patient education pamphlets that provide more detailed information about each medication you will receive. Be sure that you read and understand this material. If you don't understand, contact your nurse and ask for additional explanation. Here's why: all of this becomes especially important when you need to go to your treatment center or into the hospital to help assure that you receive the specific medication regimen prescribed for you. Also, you will be in a better position to recognize side effects when they do occur, in order to call them to your doctor's attention. In this way, a bad reaction might be treated earlier, possibly preventing more serious harm.

Remember that some of medications that you take may be given in a generic form in the hospital so the medication you receive may correctly appear different in size, shape or color. On the other hand, it is also possible that a medication name on your chart might be misread or a verbal communication misheard. Therefore, have your nurse confirm the medication with you before taking it, especially if you are unsure.

In one case recently, a mother prevented an error when she questioned the brown color of an injectable medication already loaded into a syringe. The nurse told the mother it was her child's Imferon“, which is a form of iron injection. But when the nurse was asked to check further, she found that the medication was supposed to be interferon, an important drug that was prescribed for the treatment of her child's leukemia. The mother's action prevented her child from receiving the wrong medication. So, if you do have a question about a medication, do not take it until the conflict is successfully resolved to your satisfaction. Ask your nurse to identify all your medications by name and dose and always be ready to serve as part of the check system by knowing what you are supposed to get.

It is essential that your nurse confirm who you are by checking your identity before receiving any medications. In the hospital you will be given an identification band to wear on your wrist. Make certain that the nurse checks this before any treatments are given. This is especially true when you are unfamiliar with the nurse. If your identification band has not been checked, inform the nurse of your name and make sure the medications are intended for you. In a doctor's office or treatment center, make sure that you always take the time to properly identify yourself by stating your full name rather than just confirming the name you thought you heard the nurse say. Also, ask the nurse to match your address with the address on her records. Surprisingly, two patients with the same surname might be present in the office at the same time. Or, sometimes, in the rush to get therapy underway, it is even possible for people not to realize that the wrong patient's name has been called.

Prior to receiving your chemotherapy medication, it is essential you know the regimen that you doctor has ordered especially for you. In this way you can question anything that isn't familiar later, during the course of your treatment. For example, know if you are to receive hydration (extra IV fluids to protect your kidneys from the effects of the chemotherapy) or antiemetics (medication to prevent nausea) before you receive your chemotherapy. If you've been told that hydration will be necessary, don't let chemotherapy begin without it, unless a decision was made to change your treatment regimen (if so, this should have already been explained). In the same way, know what your chemotherapy will look like, including color and amount of fluid in the intravenous bag or syringe (chemotherapy that is injected is not always clear in color; it can be yellow, red, purple, or other color). You also need to be familiar with how long the medication will infuse. It may be fifteen minutes, hours or even days. Also, know how often the chemotherapy is to be given. Some courses of chemotherapy are given daily over a four or five day period while other therapies are just given once. Some courses of therapy are repeated every three or four weeks while others are not. Some chemotherapy must be given manually (injected IV from a syringe by a doctor or nurse) while in other cases it is given as a constant infusion, controlled by an electronic pump. Again, be sure to question anything that doesn't seem right. Then be sure to get a plausible explanation for the change from both the doctor and the nurse!

Record all chemotherapy that you receive. Some of these medications, such as doxorubicin, have a lifetime maximum dose that can not be exceeded. This is important since you may receive your first chemotherapy in the hospital and then have the rest of your therapy in a different facility such as an outpatient setting. Your oncologist and pharmacist will be familiar with the maximum doses of these medications but it's not impossible for some of the previous doses to be overlooked.

Different facilities (teaching hospitals, community hospitals, clinics, etc.) have different procedures for prescribing, preparing, and administration of chemotherapy. Many practice sites only oncologists or specially trained nurse practitioners to prescribe, have pharmacists dedicated to chemotherapy preparation, and nurses who are certified to administer chemotherapy. However, this is not always the case. Therefore, it is important that you know your facility's policies before receiving your chemotherapy. You should considering choosing a facility that has a pharmacist preparing these medications because this will allow for an optimum system of independent checks between the health care providers. The pharmacist can verify the doctor's order is appropriate while the nurse can independently review the pharmacist's dispensing and preparation accuracy by checking the dosage, name of the medication, and patient's name is correct. If you are being treated in a facility without a pharmacy, ask personnel to explain the check systems that are in place. At a minimum, at least two professionals should check every prescription before chemotherapy is prepared. Then, at least two professionals should check the final preparation with the prescription.

Remember, as a patient, you are part of the check system that helps to assure medication safety. Be assertive. Ask your health care providers questions about your chemotherapy and expect thorough answers. If you do not completely understand the response, keep asking until you do. Take notes because it is difficult to remember the names, doses, and course of therapy of these medications. People who are shy or feel intimidated by the doctors and nurses should ask a family member or friend to be their advocate and accompany them to the doctor's office or hospital. Then make sure you ask when the chemotherapy is going to be administered so that your advocate can be there for involvement in the check system. One advocate was able to avoid a critical medication error when the doctor inadvertently switched how many times the chemotherapy and antiemetic medications were to be given. Chemotherapy that was supposed to be given only once was ordered for three doses. An accompanying antiemetic was ordered only once when it was actually intended for three doses. When the nurse attempted to administer a second chemotherapy in the same day, the advocate was there to mention that chemotherapy medication had already been given that day. Simply by speaking up she was able to avoid a serious medication error.

Despite many frustrations with the slow resolution of some product-related problems in the US, it is clear that practitioners' efforts to report medication errors to the United States Pharmacopeia (USP), ISMP and FDA have not been in vain. We have learned much from practitioner reports, including evidence that a large percentage of medication errors are attributable, at least in part, to commercial labeling, packaging, and nomenclature issues. As a result, the US pharmaceutical industry, USP, and FDA have been given sufficient information upon which to base improvements in labeling, packaging and naming of pharmaceuticals aimed at reducing the risk of errors. However, our recent interactions with ISMP Canada demonstrate that, all too often, the pharmaceutical industry has failed to apply many life-saving lessons learned in the US to the same products used in other countries. This leaves patients throughout the world at risk of harm from the very same problems that have already been addressed in the US. Some examples:

∑ When LOSEC (omeprazole) was launched in 1989, it was often confused with LASIX (furosemide). Scores of mix-ups and at least two related deaths were reported. As a result, the brand name was changed to PRILOSEC in the US. Yet, Losec remains the brand name in other parts of the world, and in some countries such as Canada, it is still being confused with Lasix.

∑ After a number of fatalities were reported from inadvertent intrathecal injection of vincristine, USP and FDA issued requirements for US manufacturers to visibly place a warning label on the package. In addition, practitioners are required to place a warning label, "FATAL if given intrathecally. FOR IV USE ONLY," on extemporaneously prepared syringes. The syringe must also be placed into an overwrap with this special warning, which is supplied by the manufacturer. Yet, these label and practice changes have not been required or made available to practitioners in other countries, such as Canada or the United Kingdom (UK), and fatalities in children and adults continue to be reported. In one recently published editorial related to a teenager's death in the UK (Berwick DM. Not again! BMJ 2001;322:247-8) the author notes that 13 identical cases of intrathecal vincristine have occurred in the UK since 1985.

∑ Recognizing that a 10-fold overdose may occur if the abbreviation "U" (units) is mistakenly read as a zero, or if the decimal point before a trailing zero is not seen, USP specifically bans these designations on US product labels. Yet in Canada, a manufacturer's container of insulin cartridges expresses the concentration as "100U/mL, 3.0 mL cartridges."

∑ After numerous mix-ups between potassium chloride concentrate and other medications, USP and FDA required US manufacturers to package only potassium chloride concentrate vials with a black cap, and to list clear warnings, "must be diluted" on the cap, vial ferrule, and in a box on the front label panel. In Canada, a plastic ampul of the concentrate contains only a small black mark on the snap off portion. Labeling requirements similar to those in the US are lacking.

∑ In Canada, vials of the neuromuscular blocking agent, QUELICIN (succinylcholine), are devoid of any warning about it being a paralyzing agent that causes respiratory arrest (therefore requiring artificial ventilation when administered). In the US, the vial cap and ferrule state, "Warning: paralyzing agent," and similar warnings appear on the front label panel.

If manufacturers and regulators of products used worldwide fail to translate the lessons we've learned in the US into the wider global market, is there any reason to believe that the US is benefiting from lessons learned in other countries? Are there ways for us to learn about label, package, and nomenclature improvements made in other parts of the world? Are lessons learned in other countries being translated into industry actions here, or are we just waiting for accidents to happen in the US in large enough numbers before taking action? While so much of our improvement efforts have been reactive to date, FDA and pharmaceutical manufacturers in the US are now beginning to routinely analyze proposed brand names, labels, and packages to determine error potential before product approval. Now, it is time for global pharmaceutical industry leaders to understand and give their full support to cooperative improvement efforts, both reactive and proactive, which are implemented everywhere products are used. Both ISMP Canada and ISMP Spain are committed to working with ISMP (US) and facilitating this effort with the pharmaceutical industry and regulatory agencies in their respective countries. Despite language differences, the information contained in a product's name, package, and label is universal and must be clear for all pharmacists, physicians, nurses and patients worldwide who must make decisions based on the information presented.

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