Mapping checking medication procedures may reduce the likelihood of errors during drug administration for patients with cancer, according to a study published in the Journal of Oncology Practice.1

Standard checking procedures within hospitals may function as safety barriers. Some hospitals, for example, require that hospital staff double check that the correct chemotherapy is being administered; this can, however, lead to a greater likelihood of error, given that double checking may lead to both staff members checking less closely. Mapping how hospitals standardize chemotherapy checking can improve standards and checking efficacy.

For this study, authors aimed to “(1) compare the checks among three hospitals, with ambulatory and inpatient settings, as well as between administration routes (IV [intravenous], oral, and intrathecal); (2) investigate differences among professional groups in types and number of checks applied; and (3) get a holistic overview of when checks occur along the medication process phases.”

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Two of the 3 hospitals evaluated were teaching centers; 1 was a regional hospital. The researchers analyzed internal guidelines and interviewed 15 employees overall (3 pharmacists, 6 nurses, and 6 physicians) to map standard medication checking procedures.

Checking was inconsistent between the hospitals; the lowest number of checks, however, was done during the prescription phase. No hospitals relied on single-person double checking or technology-based checking. Double checks were most common after medication production and before administration.

While checks were documented thoroughly in all 3 centers, there were no internal standards for physician checks.

The authors concluded that “application of a check uses valuable human resources, so adequate checking procedures should be defined that allow for the best possible identification of medication errors.”


  1. Pfeiffer Y, Gut SS, Schwappach DL. Medication safety in oncology care: mapping checking procedures from prescription to administration of chemotherapy. J Oncol Pract. 2018 Feb 26. doi: 10.1200/JOP.2017.026427 [Epub ahead of print]