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Oral anti-cancer medicines: risks of incorrect dosing

Risks of incorrect dosing of oral anti-cancer medicines
Reference number
1040
Central Alert System (CAS) reference
NPSA/2008/RRR001
Issue date22 January 2008
Action date (if applicable) (date field)22 July 2008
DH Gateway reference
9377
TypeAlert
This Rapid Response Report alerts all healthcare staff involved in the use of oral anti-cancer medicines to potentially fatal outcomes if incorrect doses are used.


Oral anti-cancer medicines are used in hospitals and in the community. Risks are increased if non-specialist practitioners prescribe, dispense or administer them and bypass the normal safeguards used for injectable anti-cancer medicines.


The National Reporting and Learning Service received reports of three deaths and a further 400 patient safety incidents concerning oral anti-cancer medicines between November 2003 and July 2007. Half of these reports concern the wrong dosage, frequency, quantity or duration of oral anti-cancer medicines. It is also likely that there are substantial numbers of unreported incidents.


The number of orally active agents available, particularly the targeted therapies, is likely to increase substantially in the near future. The term oral anti-cancer medicines includes those with direct anti-tumour activity and targeted therapies such as kinase inhibitors. It does not include hormonal or anti-hormonal therapy used to treat cancer.


Doctors, nurses, pharmacists and their staff must prescribe, dispense and administer oral anti-cancer medicines to the same standard as injected therapy and must be monitored in the same way.
Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
Oral anti-cancer medicines - Rapid Response Report
Oral anti-cancer medicines - Rapid Response Report - 44 KB 1040 - Oral anti-cancer medicines - Rapid Response Report - 2008-01-22 - V1
Oral anti-cancer medicines supporting information - Rapid Response Report
Oral anti-cancer medicines supporting information - Rapid Response Report - 32 KB 1040A - Oral anti-cancer medicines supporting information - Rapid Response Report - 2008-01-22 - V1