Design and implementation of a lomustine circuit as a safe practice

Abstract

Introduction

Patient safety is a fundamental objective in healthcare practice, aiming to prevent errors and avoid their impact on patients. A significant proportion of these errors occur at the household level, where monitoring is particularly challenging.

Methods

According to the principles of safety culture, Reason's model of error suggests that human errors can be mitigated through the design of more robust systems that reduce the likelihood of their occurrence. Cytotoxic drugs, such as lomustine, are classified as high-risk medications due to their potential to cause severe harm to patients.

Results

Following an incident in which a patient ingested a higher-than-prescribed dose of lomustine, a root cause analysis (RCA) was conducted. This analysis identified critical points in the process that contributed to the error, enabling the design of a comprehensive medication circuit. This circuit was developed collaboratively by the Oncology and Pharmacy departments and addressed key stages such as prescription, validation, custody, and dispensing.

Conclusion

The implementation of a structured lomustine circuit successfully eliminated medication errors associated with its use. Since its introduction, no further incidents have been reported, indicating improved safety and reliability in the medication-use process.