BD Oncology

Reducing errors within Oncology

Hazardous drugs, specifically the subgroup of chemotherapy drugs, have been described as the greatest chemical hazard present in the health field and some of the most dangerous chemical agents ever developed.1 So, error reduction surrounding their use is paramount in ensuring patient safety.

What’s more, reducing errors brings the opportunity to improve efficiency, as well as cutting costs. That’s why it is such a priority in every aspect of oncology. To achieve this, departments need to adopt multiple strategies to improve the accuracy of the medication process, which includes the integration of new technology.

We have reviewed existing research to identify the scale, scope and causes of errors in oncology, and suggested solutions to address them.

Where are these errors occurring?

Until zero errors occur, the level of medication errors in oncology is still too high and therefore there is clearly room for improvement. Data from published literature of European studies highlights the specific level of errors in each step of the med journey:

Prescribing Phase – a study conducted in Ireland reported 29% of handwritten chemotherapy prescriptions contained at least 1 prescribing error or omission2. Using the findings from a separate study that reported 1.8% of these types of prescribing errors would not get intercepted3, this equates to approximately 6% of the errors within the Ireland study potentially reaching the patient.

Preparation Phase – a large multicentre study in Europe involving 759,060 chemotherapy preparations showed the mean out-of-tolerance error rate during compounding to be 10.44%4

Administration phase - a large observational study carried out in both an inpatient and outpatient oncology setting reported the risk of administration errors of intravenous (IV) chemotherapy to be 27.3%5

Medication errors can occur at any stage. As they could result in both serious toxicity to the patient, or underdosing and therefore suboptimal patient outcomes, error prevention at all stages is crucial.

A closer look at errors in the prescription phase

This issue was addressed by Ranchon in the European Journal of Cancer6. This study aimed to identify the predictors of prescription errors involving anticancer chemotherapy agents. The study was conducted in a large university hospital in France and analysed 17,150 chemotherapy prescriptions. Prescription errors were defined as failures in the treatment process, which led to, or had the potential to lead to patient harm.

The following independent predictors of risk of prescribing errors were identified:


Patients with a body surface area >2m2

Protocols with more than three drugs

Protocols involving carboplatin

Protocols requiring at least one modification by the physician

Prescriptions by a resident physician


How to reduce prescription errors

Two independent studies showed that Computerized Physician Order Entry (CPOE) systems cut medication error rates in a hospital by approximately two-thirds7,8. CPOE systems achieve this by providing standardized protocols, aligning the prescription with the patient’s latest clinical results, providing dose calculations and cumulative dose information, and automatically alerting the prescriber if a dose is outside the recommended limits. They also ensure clear and legible prescriptions, decreasing the risk of errors that can be brought about with look-alike drug names.

Additional safe practices to consider in reducing prescribing errors include:


The use of checklists

Prohibition of verbal orders

Avoidance of ambiguous abbreviations9

Consideration of ordering history and consultation of patient’s medical records

Thorough knowledge of chemotherapy protocols8


A closer look at errors in the compounding phase

A 2018 Canadian observational study investigated IV chemotherapy compounding latent errors10. A latent error is an underlying potential human failure, for example the storage of look-alike drugs besides each other. Within the study, 11 latent errors were identified across four cancer centres in Canada, all of which could lead to the death, or permanent loss of function among patients with cancer. These 11 latent errors are detailed below, grouped by process category:

Transcription of the prescription

  1. Compared with electronic transcription, human transcription is error prone. If an error in transcription were to occur, it has the potential to propagate downstream through the system, meaning that a patient could receive a preparation that contains any type of error, including wrong drug or wrong dose.

Assembly of materials

  1. Assembly of more than one preparation per tray creates the potential for the wrong drugs, syringes, final containers, preparation instructions, and/or labels to be loaded into the Biological Safety Cabinet (BSC) which would lead to compounding errors.


  1. If an error in reconstitution occurs, no way of detecting it downstream may exist and could result in a significant dose error. Drug-specific reconstitution protocols and independent reconstitution checks, therefore, are critical.
  2. One site had a single document outside and to the right of the BSC that listed all the drugs’ reconstitution instructions. Therefore, a technician would need to lean outward and scan the whole document to find a specific drug’s instructions and then interpret them correctly.
  3. Another site had no live inspection of reconstitution: The pharmacist verified reconstitution only after the completed preparation had left the clean room.

Preparation of the drug

  1. The two sites that assembled patients’ preparations in the same tray also sometimes had one or more preparations in the BSC at once. A mix-up of drug, dose, and/or label, therefore, was possible.
  2. Three of the four sites chose to avoid removing partially used vials of chemotherapy drugs from the BSC until the end of the day. The risk of having additional high-risk vials in the BSC along with the target vials is the same as having more than one preparation at a time.
  3. To reduce environmental waste, one site reused a syringe as many times as necessary to achieve a target volume. Without being able to see all the syringes at once, reliable confirmation of the total volume is difficult.

Verification and labelling of the compound preparation

  1. Two of the four sites used a variant of the denounced syringe pullback method. At both sites, the preparer’ would withdraw the drug into the syringe and inject it into the final container without direct observation by a second individual. Although a weight-based check could catch potential preparation errors, some errors could easily be missed. For example, an error in re-constitution could be made but the correct volume of drug withdrawn, or two errors could cancel each other out to create the correct weight
  2. At two sites, the ‘preparer’ spoke aloud the name and volume of drug just withdrawn, for example, “five of cyclophosphamide.” Telling the checker what to expect can create confirmation bias.
  3. At two of the four sites, administration labels were affixed after the preparation left the BSC, which created the potential for the labels to become lost and/or mixed up and, ultimately, applied to the wrong final container.

How to reduce compounding errors

Automated IV medication workflows using gravimetric technology can be used for the preparation of cytotoxic drugs instead of the traditional manual workflows using volumetric preparation. Automated workflows provide step-by-step instruction to guide the user through the compounding process, and combined with barcode scanners, gravimetric scales and cameras, help ensure the correct preparation of a drug.

Two studies reported evidence showing the benefit of automated IV medication workflows (BD Cato™) with regards to reducing compounding errors:

Reece 2016 described the implementation and evaluation of a gravimetric IV workflow software system in an oncology ambulatory care pharmacy11. Over the study period, 51,037 chemotherapy doses were prepared without a workflow software system, with a total of 49 errors (0.096%) reported. 15,843 doses were prepared utilizing the new technology, with a total of 1,126 errors (7%) detected by the workflow software during dose preparation; barcode scanning detected 292 (26%) of the total errors, the gravimetric weighing step detected 797 (71%) deviation errors, and 37 (3%) errors were detected at the vial reconstitution step. The implementation of this workflow software system resulted in an over 74-fold increase in the detection of medication errors and allowed the errors to be corrected before completion of the dose, unlike without the software system.

Terkola 2017 aimed to detect medication errors with possible critical therapeutic impact in 10 centres across five European countries following the introduction of a gravimetric IV workflow software system5. The mean out-oftolerance error rate across the 10 centres, which prepared 759,060 chemotherapy doses, was 10.44%. The proportion of chemotherapy preparations with deviations >10% of the target dose ranged from 0.49% to 5.04%, with a mean of 2.25%. It is highly likely these errors would have gone undetected using traditional volumetric preparation. Additionally, all the errors detected with the gravimetric system during the preparation process did not need to be corrected postproduction, resulting in a reduced technician compounding time and reduced pharmacist preparation time of 34% and 37% respectively.

A closer look at errors in administration phase of oncology

Administration of chemotherapy is an important aspect of cancer nursing. Treatment regimens typically involve several chemotherapeutic and supportive agents, many of which require individualized dosing (e.g. body surface area, renal function), are administered by a variety of routes (e.g. orally, IV), and at different rates (e.g. bolus, continuous infusion). Delivery of a regimen on one day of a patient’s cycle can take several hours and involve multiple nurses. This complex and dynamic nature of chemotherapy administration makes the process highly vulnerable to errors.

In a prospective, systems-focused clinical risk assessment at an oncology unit in a large city hospital in the United Kingdom, several specific chemotherapy failure modes relating to chemotherapy administration were identified, the majority of which had not previously been recognized12. These are shown in the table below.

Identified Failure Modes and Related Hazard Scores

Failure Mode Hazard Score
The patient fails to arrive for his or her appointment and chemotherapy is not given that day (when it should have been). 4
Based on the patient’s fitness markers, it is wrongly concluded that he or she is unfit for chemotherapy and it is not given that day (when it should have been). 4
Some of the equipment or drugs are (completely) unavailable and chemotherapy is not given that day (when it should have been). 4
Chemotherapy administration is delayed or prolonged (i.e.; the patient’s stay in hospital is prolonged). 8*
Chemotherapy is administered to a patient unfit for it (based on the markers of the patient’s fitness). 4*
Chemotherapy is administered to a patient who has not consented to it. 2
A drug(s) not on the prescription is administered. 8*
A drug(s) intended for a different patient is administered. 12*
A chemotherapy regimen is administered to the wrong patient. 4
An element(s) of the drug regimen is (wrongly) administered twice (i.e., a double dose is given). 8
An infusion bag is removed before all the contents have infused (i.e., an underdone is given) 4
For a drug whose full dose comes in two or more syringes or bags, only one or some of them are given (i.e., an underdone is given) 12*
The wrong dose of a drug (whose dose is dependent on surface area) or some of them are given (i.e., an underdone is given) 8*
A patient with a peripherally inserted central catheter is cannulated. 3
Bolus drugs are given as infusions. 4
A bolus drug is administered too quickly. 8
An infusion pump is wrongly programmed (i.e., the drugs are infused at the wrong rate). 9*
An infusion pump stops during the infusion and is not immediately noted and restarted. 8*
A drug(s) from the regimen is omitted (i.e., not administered). 16*
An expired drug(s) is administered. 8*
The drugs that compromise the regimen are not administered in the optimal order. 8*
A chemotherapy drug that needs to be is not protected from light during infusion. 4
The patient has an allergic reaction. 16*
Extravasation occurs. 12
There is air in the IV line. 4
The IV line is flushed with a cytotoxic drug rather than a compatible fluid, such as saline. 4
The IV line is flushed with the wrong compatible fluid (e.g., saline instead of dextrose). 4
Infection is introduced to the patient during the chemotherapy administration process. 8
The cannula site or the peripherally inserted central catheter is not dressed properly at the end of the patient’s stay. 16
There is a cytotoxic drug spillage. 12

Note: Scores ranged from 1-16. Higher scores equal more hazard. *Priortized failure mode.

The study concluded that steps therefore need to be taken to address the failure modes identified, especially those with high hazard scores.

Reducing errors in all phases of the oncology medication process

Human error will always be a risk within a medication process as demanding and complex as in oncology. However, technological and process-driven solutions like BD CatoTM can help an organization make significant improvements in reducing errors. These reductions increase patient safety and have consequent efficiency benefits for pharmacy and the oncology department as a whole.


Where BD can play a part

  • Prescription
  • Preparation
  • Administration


BD Cato™ Prescribe


BD Cato™ Pharmacy
BD PhaSeal™
BD MicroBore


BD MicroBore
BD Cato™ Med(ReadyMed)
BD BodyGuard™ Duo BCMA

Beyond the reduction of errors, within BD we are working across all aspects of oncology to continuously optimise patient outcomes by providing connected workflows and automating manual processes, while continuing to protect healthcare workers. We work with our partners, clinicians and healthcare professional to provide a seamless end-to-end solution for all oncology professionals.

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