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National Patient Safety Agency

NPSA makes anti-cancer medicine recommendations following patient safety incident review

28 October 2010

The National Patient Safety Agency (NPSA) has issued a series of recommendations to all NHS organisations across England and Wales aimed at improving care and minimising risk associated with anti-cancer medicines.


‘A themed review of patient safety incidents involving anti-cancer medicines,’ was produced following 4,829 patient safety incidents reported to the NPSA between 1 November 2003 and 30 June 2008.

Wrong/unclear dose, strength, frequency or quantity of anti-cancer medication was the largest category of patient safety incidents reported to the NPSA (1,569). Eleven of these incidents were associated with death or moderate or severe harm.  


The review analyses trends of patient safety incidents during the five year period and features case studies of where errors occurred. The review is also recommending NHS organisations ensure:


• all clinical protocols, prescriptions and all other documents are written in a clear manner to minimise misunderstanding or error;

• clear policies and procedures are in place which identifies those members of staff who are authorised to prescribe and perform other duties with anti-cancer medicines;

• any alterations to standard anti-cancer protocols are clearly described if modified in response to individual patient circumstances;

• adequate safeguards are in place for prescribing, dispensing and administering supportive treatments (such as Mesna or hydration fluids) alongside the anti-cancer medicines. 


Cathy Hughes, Patient Safety Lead for Cancer at the NPSA, said: “Whilst the vast majority of patient safety incidents reported to us have resulted in no or low harm, incidents resulting in patient death have been reported and there is a real potential for serious harm or death to occur if anti-cancer medicine is not handled appropriately.”


Dr Hughes added: “This is a really detailed study covering a five year period that is aimed at supporting healthcare professionals to further improve standards. We recommend NHS organisations review the key findings and actions within the report and make necessary changes to further strengthen patient safety within their services.”


This latest review supports the recommendations contained within the National Confidential Enquiry into Patient Outcome and Death’s (NCEPOD) ‘For Better, For Worse?’ which reviewed patients who died within 30 days of receiving systemic anti-cancer medicines. It also builds upon the National Chemotherapy Advisory Group’s report ‘Chemotherapy Services in England: Ensuring quality and safety.’


Dr George Findlay, Lead Clinical Coordinator at NCEPOD, said: "The report ‘For Better, for Worse?’ highlighted serious deficiencies in the care of patients dying within 30 days of systemic anti-cancer therapies. This NPSA review supports these concerns and builds upon the good recommendations already made by NCEPOD and the National Chemotherapy Advisory Group. It is incumbent on the profession to learn from this work and improve the quality of care that patients receive".

For a copy of the report, please visit http://www.nrls.npsa.nhs.uk/resources/?entryid45=75475


Notes to editors


1. Media enquiries to the NPSA Press Office:

Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk


Out of hours – 0788 411 5956


2. Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.  This aspect of our work will continue within the new proposed structure of the NHS Commissioning Board and we will continue to work together in partnership with NHS organisations to make services even safer for patients.  We will continue to monitor the implementation of all patient safety alerts and guidance.