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National Patient Safety Agency

Patient safety risks of incorrect dosing of oral anti-cancer medicines

23 January 2008


The National Patient Safety Agency (NPSA) today warned of potentially fatal outcomes if incorrect doses of oral chemotherapy drugs are administered. The NPSA raised concerns that the risks of prescribing, dispensing and administration errors are potentially increased if the normal safeguards used for injectable anticancer medicines are not applied.


The NPSA recorded three deaths and over four hundred patient safety incidents concerning oral anticancer therapy between November 2003 and June 2007. Half of these reports concerned the wrong dose, strength, frequency or quantity of oral anticancer therapy.


“There are greater demands made on non-cancer specialists to manage oral chemotherapy and increasingly this is occurring in the community so we are recommending that, where appropriate, safeguards in place when managing injectable chemotherapy are applied to oral chemotherapy. The Rapid Response Report aims to raise awareness of the risks and highlights measures to help improve the safety of patients” said: Professor David Cousins, Head of Safe Medication Practice at the NPSA.


Key recommendations include the requirement that chemotherapy is initiated by a cancer specialist and non-specialists who prescribe, dispense or administer on-going oral anti-cancer medication should have ready access to appropriate written protocols and treatment plans including guidance on monitoring and treatment of toxicity.


Nearly 18 million doses of chemotherapy were used in hospitals and six million doses in the community in England during 2006.


A copy of the Rapid Response Report - Risks of incorrect dosing of oral anti-cancer medicines, reference: NPSA/2008/RRR001 and a document containing some of the related background/reference information are available at www.npsa.nhs.uk/patientsafety/alerts-and-directives/rapidrr/risks-of-incorrect-dosing-of-oral-anti-cancer-medicines


Notes to editors

1. For further information please contact Senior Communications Manager, Nick Rigg on 0207 927 9362. 


2. The National Patient Safety Agency (NPSA) helps the NHS learn from its mistakes so that it can improve patient safety. It does this by collecting reports on errors and other things that go wrong in healthcare so that it can recognise national trends and introduce practical ways of preventing problems. It does not investigate individual cases or complaints, but it does listen to public concerns and uses what is said to improve safety.


3. NPSA Rapid Response Reports are a new concise information format to communicate rapidly with NHS professionals about important patient safety issues. The one-page document provides early warning about an issue and is different from existing NPSA products such as Patient Safety Alerts and Safer Practice Notices.