Ordering Errors Were Identified
On the basis of a selective literature review, Hoffmann et al. report on the epidemiology and etiology of avoidable serious adverse events. Their excellent review article clarifies that 70–80% of the population regard medical errors as an important issue, and 29% are worried that in case they contract an illness they might be subject to treatment errors themselves. Retrospective analyses have shown that 4% of treated inpatients do experience adverse events, of which at least half are avoidable. It is of interest that the estimated death rate due to avoidable errors of 0.1% seems low; however, in view of 17 million inpatients, this corresponds to 17 000 deaths per year. The authors regret that studies investigating this issue are lacking in Germany; albeit these studies do exist for highly complex and potentially toxic medications, namely chemotherapies.
We assessed 22 216 chemotherapeutic orders for 2337 patients receiving chemotherapeutic treatment in our department from 1/2005 to 12/2006 in regard to their correctness and identified 3.8% ordering errors (1). Of these 3792 ordering errors, 99.9% were corrected and successfully avoided by our quality control management and did not get passed on to the patient. This error rate confirms a publication from Boston (2), which also described a 4% error rate for ordered chemotherapeutic regimens, of which merely 45% were avoided. Assuming that each serious medication error incurs follow-up costs owing to complications of € 1000, then 3792 chemotherapeutic errors would result in costs of € 3,792,000. Implementing our clinical service system helped to reduce these assumed costs by a factor of 1264. Our clinical service system, a quality control management team, is comprised of physicians, pharmacists and an additional medical technician. This medical technician monitors all chemotherapy orders and uses 25% of her time to check 50–100 orders of chemotherapeutic regimens per day. The additional staff cost per chemotherapeutic order accounts for 1€.
Our data confirm and add to the article by Hoffmann et al., emphasizing that dealing transparently with errors to support avoidance of severe adverse events is indispensable for safe medication. Our results were enthusiastically discussed by the Frankfurter Allgemeine Zeitung under the heading “Kontrolle zahlt sich aus [control pays off]” (3), and our achievements in safe patient medication care was awarded first prize of the Quality Award from the Freiburg University Medical School Center in 2009
Prof. Dr. med. Monika Engelhardt
Dr. rer. nat. Ulrike Kohlweyer
Dr. med. Martina Kleber
Universitätklinik Freiburg, Hämatologie & Onkologie
Hugstetterstr. 55, 79106 Freiburg, Germany
Conflict of interest statement
The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.
|1.||Markert A, Thierry V, Kleber M, Behrens M, Engelhardt: Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment. Int J Cancer 2009; 124: 722–8. MEDLINE|
|2.||Gandhi TK, Bartel SB, Shulman LN, et al.: Medication safety in the ambulatory chemotherapy setting. Cancer 2005; 104: 2477–83. MEDLINE|
|3.||Lenzen-Schulte M: Kontrolle zahlt sich aus – In Freiburg überprüft ein Ärzteteam Chemotherapien. Frankfurter Allgemeine Zeitung, Natur und Wissenschaft, 11. 2. 2009.|
|4.||Hoffmann B, Rohe J: Patient safety and error management — What causes adverse events and how can they be prevented? [Patientensicherheit und Fehlermanagement: Ursachen unerwünschter Ereignisse und Maßnahmen zu ihrer Vermeidung]. Dtsch Arztebl Int 2010; 107(6): 92–9. VOLLTEXT|