With Oral Chemotherapy, We Simply Must Do Better!

PROBLEM: Many health care organizations have focused on improving safety with parenteral chemotherapy but have done less to ensure safe practices with oral chemotherapy. Although oral chemotherapy is associated with ease of administration, an error with an oral agent can be just as deadly as an error with a parenteral formulation. Two years ago Ruth Ann Collins, a 60-year-old woman with a history of brain cancer, died a slow, painful death after accidentally taking the equivalent of three cycles of oral lomustine (Gleostine, Corden Pharma) therapy at one time (450 mg), believing the pharmacy had dispensed just a single dose (150 mg).