6 ways to avoid fluorouracil medication errors: ISMP

The Institute for Safe Medication Practices (ISMP) is cautioning hospital pharmacists and other healthcare professionals about the intravenous cancer medication fluorouracil.

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The organization has received 3 reports of accidental overdoses with fluorouracil in 2015 – 2 within the past 6 weeks. More than 250,000 patients receive fluorouracil annually, according to the National Institutes of Health, and around 8,000 experience a toxic reaction. Around 1,300 patients die each year from toxicity.

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Impaired clearance of the drug and medication errors are usually responsible for these adverse events, according to ISMP.

In the most recent case reported to ISMP, a young patient received 4,500 mg of fluorouracil IV within 2 hours of starting the infusion, which was supposed to infuse over 46 hours. The patient received the fluorouracil via a new CADD ambulatory infusion pump, which had been programmed incorrectly, delivering the full 2-day course over 2 hours.

To prevent similar errors with fluorouracil, ISMP provided these recommendations:

#1. Standardize how key information is displayed on pharmacy labels. Ensure that the information needed to program an infusion pump, such as total volume, concentration and hourly rate of infusion, is prominently displayed in a standard and consistent way on pharmacy labels, sequentially matching the information that the nurse needs to enter into the infusion pump fields, ISMP wrote. Eliminate extraneous information, such as “mL per 24 hours”, and communicate infusion rates as an hourly rate only.

#2. Prescribers should order fluorouracil clearly in single daily doses (not course doses) with directions to infuse continuously over a specific number of days or hours.

#3. Use pumps with safeguards. “Smart pumps for use in ambulatory care settings are available, and their use should be encouraged to maximize safety features such as dose alerts, dosing and flow rate limits, and operator feedback to allow detection of pump programming errors,” ISMP wrote. If possible, use only one type of ambulatory pump throughout the organization.

#4. Review the processes by which certification is granted to prescribers, pharmacists, and nurses who order, dispense, and administer fluorouracil and other chemotherapy. Make any changes necessary to ensure that staff exhibit and maintain an appropriate level of skills, knowledge, and abilities before working independently.

#5. Provide education and validate competency. Educate staff to program and connect ambulatory infusion pumps and elastomeric pumps that are used at the facility.

#6. Enhance independent double checks. “Promote critical thinking during the preparation and checking of all chemotherapy. Develop a structured process for conducting and documenting independent double checks, after preparation and prior to administering fluorouracil (and all chemotherapy agents),” ISMP wrote. Design checklists to facilitate compliance with all the steps necessary in the checking process. Establish how verification can be accomplished if only one practitioner is on duty, or if home care nurses provide care in the oncology clinic or in the home.