Inappropriate continuation of medication when patients are admitted acutely: the example of capecitabine
Some cytotoxic drugs which are widely used to treat cancer are administered orally. Any hospital which has an emergency department (ED) must expect to admit patients who are taking oral chemotherapy drugs prescribed locally or elsewhere. The risks of repeat prescriptions of these medicines have long been recognised.1 The warning on this subject, issued by the UK National Patient Safety Agency,2 reported 445 incidents; 187 (42%) concerned capecitabine (Xeloda®), an oral chemotherapy agent used singly or in combination with other drugs to treat a variety of cancers particularly of the breast and gastrointestinal tract. This treatment was the second most common to be associated with death shortly after chemotherapy in the study by the National Confidential Enquiry into Patient Outcome and Death.3 This is a consequence of myelosuppression or severe mucous membrane toxicity associated with this drug.4
Policy for admissions to this hospital is that oral chemotherapy drugs are not prescribed until the patient has been reviewed by an oncologist. However, we identified six patients on capecitabine where this was not followed. Five of these patients were taking it within combination chemotherapy, the other drugs being given intravenously. Four patients were admitted for reasons not directly related to chemotherapy toxicity. The other two patients were pyrexial but not neutropenic and had recognised sources of infection. All the patients had brought in their drugs from home and, in all cases, it would seem that they were routinely transcribed onto the inpatient prescription by the admitting junior doctor without the appropriateness being questioned.
Work with emergency admissions is an essential part of medical training. It is important that undergraduates and junior doctors are educated to understand that the prescription of any medicine, including the transcription of a list of the patient's medication on admission onto an inpatient prescription form, requires an understanding of the drug concerned and thought about its appropriateness in the immediate context. Adverse effects of drugs are a common cause of emergency admissions; this is not confined to cytotoxic agents.
Patients at this hospital attend a dedicated consent clinic between the decision to initiate treatment and its commencement. There they are counselled to tell any healthcare personnel that they consult that they are taking oral chemotherapy tablets. The contact card that all patients are given at that time has a specific instruction to discontinue capecitabine if diarrhoea is experienced.
Since November 2009 all oral chemotherapy dispensed at Airedale General Hospital has a red label on the box stating that it should not be prescribed until the specialist team has been consulted (Fig 1). Our experience shows that this procedure is not infallible, one reason being that patients sometimes do not bring the labelled box with them into hospital.
This hospital's onsite oncology service designates a consultant medical oncologist to identify and review admitted patients on the next working day. The National Chemotherapy Advisory Group recommends that all hospitals with EDs should have an acute oncology service which includes this function.5 Our experience illustrates the importance of this.
Footnotes
Letters not directly related to articles published in Clinical Medicine and presenting unpublished original data should be submitted for publication in this section. Clinical and scientific letters should not exceed 500 words and may include one table and up to five references.
- © 2011 Royal College of Physicians
References
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- Crawford SM,
- Cox JA,
- Hunt KM
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- National Patient Safety Agency
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- National Confidential Enquiry into Patient Outcome and Death
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- Perry Michael C.
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- NHS National Cancer Action Team
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