Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia

Cancer. 2006 Sep 15;107(6):1400-6. doi: 10.1002/cncr.22131.


Background: Although medication errors are 1 of the most common types of medical errors, their frequency in pediatric patients receiving oral outpatient chemotherapeutic agents is unknown. The prescribing, dispensing, and parental administration of these medications to children receiving treatment for acute lymphoblastic leukemia (ALL) were systematically reviewed to determine the rate and types of medication errors occurring in these patients.

Methods: During a 2-month study period, parents of children with ALL were contacted and asked to participate in the study before a regularly scheduled clinic appointment. At the visit, the parent demonstrated how each medication was administered. A pediatric oncologist reviewed the medical record to determine the correct treatment regimen for study patients. After comparing the correct treatment regimen with what was administered, a classification of "no medication error," "medication error," or "cannot determine" due to insufficient information was made for each indicated drug. Identified medication errors were subclassified as prescribing, dispensing, or administration errors.

Results: Data on 172 chemotherapeutic medications for 69 patients were analyzed. One or more errors occurred with 17 of the 172 (9.9%) medications; a classification of "cannot determine" was made for 12 (7.0%) medications. Among the 17 medication errors there were 12 (7.0%) administration errors and 5 (2.9%) prescribing errors. There were no pharmacy dispensing errors. All errors were due to incorrect dosing or failure to administer an indicated medication. At least 1 medication error occurred in 13 of the 69 (18.8%) study patients.

Conclusions: Prescribing and administration medication errors occurred with nearly 10% of chemotherapeutic drugs administered to outpatient children with ALL. Systematic changes, including computerized physician order entry and simplification of treatment protocols, should be considered.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Oral
  • Adolescent
  • Child
  • Child, Preschool
  • Dexamethasone / administration & dosage
  • Dexamethasone / therapeutic use
  • Humans
  • Infant
  • Medication Errors / classification
  • Medication Errors / prevention & control
  • Medication Errors / statistics & numerical data*
  • Mercaptopurine / administration & dosage
  • Mercaptopurine / therapeutic use
  • Methotrexate / administration & dosage
  • Methotrexate / therapeutic use
  • Outpatients / statistics & numerical data*
  • Precursor Cell Lymphoblastic Leukemia-Lymphoma / drug therapy*
  • Prednisone / administration & dosage
  • Prednisone / therapeutic use
  • Prospective Studies
  • Thioguanine / administration & dosage
  • Thioguanine / therapeutic use


  • Dexamethasone
  • Mercaptopurine
  • Thioguanine
  • Prednisone
  • Methotrexate