A new chemotherapy near-miss reporting system significantly reduced the number of chemotherapy errors at a children’s hospital, according to a recent study.

Investigators implemented the system to supplement the hospital reporting system. The new model included a daily chemotherapy huddle, improved IV therapy preparation and delivery, headphones for clinicians ordering chemotherapy, and hospital-wide standardized chemotherapy administration guidelines. Among the results:

• Chemotherapy errors were reduced from 3.8 to 1.9 per 1,000 doses.
• There was an initial increase in error rates, followed by a significant decline after 16 months of implementing improvements.
• The improvement has continued for >4 years.