Page 47 - Q BULLETIN, Ministry of Health Malaysia, VOLUME 1, NO. 31 (SUPPLEMENT 1), JAN-DEC 2022

Q Bulletin, Volume 1, No. 31 (Supplement 1), Jan - Dec 2022
11 National QA Convention, 4 – 6 October 2022
th
PP-09

Reducing the Incidence of Near Miss Chemotherapy Errors in Oncology Department of
Hospital Kuala Lumpur

Nadiah A , Siew CJ , Chuah PL ,Abdul Fatah H , Muthukumaran T , Han AD , Nur Adamilah AP , Lee MW 1
2
2
1
1
1
1
2
1 Pharmacy Department, Hospital Kuala Lumpur, Kuala Lumpur
2 Oncology Department, Hospital Kuala Lumpur, Kuala Lumpur
SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:
Chemotherapeutic agents have a narrow therapeutic window; any errors can lead to significant harm or even
death. Between 2018 to 2020, the Oncology Department reported six cases of actual chemotherapy errors that
caused adverse events to patients. Reducing near miss chemotherapy errors can minimise the risk of actual
errors that may harm patients.
KEY MEASURES FOR IMPROVEMENT:
Near-miss errors are errors that did not reach the patient either by chance or intervened during medication
use. The standard of near miss chemotherapy errors in the Oncology Department was set at 0.6%, based on a
previous study from the literature review.

PROCESS OF GATHERING INFORMATION:
Errors detected or intervened during prescribing, preparation, dispensing or before administration of
chemotherapy were recorded in a data collection form. A survey to identify factors leading to chemotherapy
errors was conducted concurrently with the pre-remedial study in August 2020. Subsequently, remedial
measures were carried out in two cycles in November 2020 and March 2021, after which a cross-sectional
study was conducted for two months at the end of each cycle.

ANALYSIS AND INTERPRETATION:
The verification study revealed that the rate of near miss chemotherapy error was 1.15% prior to remedial
measures. Incomplete documentation, no standardisation of practice, staff inexperience, and lack of
counterchecking contributed to the problem.

STRATEGIES FOR CHANGE:
The strategies taken in the first cycle were updating the current cytotoxic drug reconstitution (CDR) request
form and conducting continuous medical, pharmacist, and nursing education. In the second cycle, further
improvement to the CDR request form was made, and the “check-it-right” checklist was introduced during
chemotherapy dispensing.

EFFECT OF CHANGE:
After Cycle 1, the percentage of near-miss chemotherapy errors reduced to 0.83%. It was further reduced to
0.52%, achieving the target set after implementing Cycle 2 remedial measures.

THE NEXT STEP:
A multidisciplinary effort is essential in ensuring 0% chemotherapy error. These strategies can be expanded to
all wards using chemotherapy in Hospital Kuala Lumpur.

43