Cancer Medication Errors Still a Problem

Medication errors occur all too frequently, as Institute of Medicine reports have noted in recent years. A new study has found that errors are even more prevalent than previously thought when treating patients with cancer, both at home and in the clinical setting.

According to University of Massachusetts Medical School researchers, medication errors occurred in 7% of adults’ chemotherapy visits and a disconcerting 19% of children’s visits. Gail Gazelle, MD, FACP, FAAHPM, assistant professor of medicine at Harvard Medical School and president of MD Can Help, said she is not surprised by the study’s results.

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“Certainly with the Betsy Lehman horrible tragedy in the mid-1990s, there began to be an awareness that there were very significant medication errors in chemotherapy,” Dr. Gazelle said. Betsy Lehman was a health reporter with the whowas undergoing experimental chemotherapy for breast cancer at the Dana-Farber Cancer Institute when she and another patient received a four-fold overdose of cyclophosphamide. Ms. Lehman died and the other patient suffered permanent heart damage, leading to major changes in medication practices at major institutions. “With the unbelievable number of Americans dieing unnecessarily because of medication errors in general, why would the oncology world be shielded from that?” Dr. Gazelle wondered.

Questioning the Study’s Methods

Thomas Cartwright, MD, an oncologist with the Ocala Oncology Center in Ocala, Florida, explained that oncologists often determine a medication regimen for cancer patients by calculating the patient’s body surface area. Dr. Cartwright said the method of calculating body surface area is controversial and might lead to dosing errors. The US population is also becoming increasingly overweight and obese, resulting in larger body surface area and subsequently larger doses—even overdoses—of medication. Dr. Cartwright believes the researchers’ reliance on this method of calculating doses may have contributed their identification of such high error rates.

“The researchers went back and recalculated the patient’s body surface area, and then if the dose varied by more than 10%, they considered that an error,” Dr. Cartwright said. He disagreed with this categorization and noted that, for obese patients, he must sometimes reduce the dose to prevent them from getting an inappropriately high dose based on body surface area. “I make a clinical judgment and adjust that dose. I don’t consider that an error,” he said.

Another problem Dr. Cartwright had with the study’s findings was how researchers handled treatment with leuprolide (Lupron), the drug the study most often associated with medication errors. Leuprolide is a long-acting drug typically administered to patients every 90 days to treat metastatic prostate cancer. Dr. Cartwright noted that the standard 90-day interval sometimes stretches to 91 or 92 days due to Sundays and holidays. The researchers flagged such incidents as medication errors. “With a long-acting drug like [leuprolide], it doesn’t make any difference if it’s a few days off,” he said.

‘Traditional’ Errors Do Occur

Although Dr. Cartwright had concerns with the study’s methodology, that is not to say there are not times when cancer patients are given the wrong dose or the wrong drug. Dr. Gazelle attributed some of the errors to cutbacks in nursing and technical staff resulting from recent Center for Medicare & Medicaid Services directives that have led to declining reimbursements for oncology services. She also noted that only 15% of physician practices have switched to electronic medical recordkeeping, which has been shown to decrease medication errors. “I think the public sort of has this idea, and many physicians have the idea, that everybody has gone electronic,” she said. “But that really is not the case.” The Obama administration has allocated millions of dollars to increase the use of electronic medical recordkeeping. Whether this effort will reduce the number of medication-related errors remains to be seen.

Dr. Cartwright cautioned that a computer program is only as effective as the data that is entered. He said he has been in practice for more than 20 years and for the last 2 years, he has used an “excellent” oncology specific EMR. “There’s probably 5000 or 6000 drugs on the market in the United States, and you can’t possibly remember all the interactions.” The problem stems from when patients fail to tell their oncologist what other drugs they are taking or those drugs are not entered into the system properly. Dr. Cartwright said unfortunately, many patients cannot remember the names of all the medications they currently use.

Partnering with and Empowering Patients

Dr. Gazelle believes physicians and patients need to work together to improve the quality of patient care. She said this is especially important in oncology, where stakes are much higher because of the potential toxicities of the medications. “It is absolutely critical for oncologists and their staff to be trained to listen to patients, and to empower patients to speak up and be active participants in all areas of care,” she said.

Dr. Cartwright agreed. He pointed out that the study notes that many medication errors occurred after patients went home. The patients misunderstood the physician’s instructions or simply did not follow them. He said, “It’s the responsibility of the physician to communicate to the patients why they’re taking the medication, how to take it, what side effects they might experience, and to ask questions if [the patients] don’t understand.”

Dr. Gazelle added, “We’re used to patients being passive recipients of the care we provide. Until we empower them to partner with us to improve the quality of their care, efforts toward improving patient safety will have limited success.”

Oncology & Biotech News

For details of this study, see the “Reimbursement & Managed Care News” section of the March issue of .