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Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process.


In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors.


Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug.
Advances in Patient Safety.


There is an urgent need to make the administration of chemotherapy to hospitalized children a less intricate, lower risk process. Children have a distinct physiology and an immature ability to metabolize drugs. Combined with complex chemotherapeutic regimens and narrow therapeutic indices, the probability and severity of adverse drug events in a vulnerable population like children are high. Given this need, near-miss chemotherapy ordering errors, and research that identifies the prescribing/ordering step as a significant source of pediatric chemotherapy errors, Memorial Healthcare System (MHS) has been working to integrate and decrease variability in the pediatric chemotherapy process. This paper describes MHS’s ongoing program of standardization and integration of pediatric chemotherapy process components using information technology to promote a culture of safe practices and continued automation implementation in a complex health care delivery system.

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