Drug therapy safety: methotrexate-associated medication errors

Abstract Aim Drug therapy safety aims at ensuring optimal medication while reducing errors and preventing avoidable patient risks. The transition from outpatient to inpatient care is especially vulnerable to medication-related problems (MRPs), including those related to transferring outpatient medication orders into electronic health records. This phase is particularly vulnerable for drugs with dose-dependent pharmacological effects, such as methotrexate (MTX). Methods Within the framework of INTERPOLAR (INTERventional POLypharmacy – drug interAction – Risks), clinical pharmacists regularly perform medication analyses as are routinely carried out across multiple departments of the Jena University Hospital (UKJ). Identified problems are addressed through interdisciplinary collaboration. The analyses rely on essential patient information, including medical history, diagnoses, clinical findings, and laboratory results, as well as current medications. Results Medication analyses identified five cases within 5 months with MRPs related to MTX across departments during hospitalization at UKJ. Conclusion Although MTX-related MRPs are well known and despite established risk-minimization measures, failures still occur. The present case series highlights the need for regular active, interdisciplinary safety strategies. These should go beyond predominantly passive informative measures. Cooperation between treating physicians and clinical pharmacists should be strengthened and made standard practice, especially during hospitalization of patients with complex or potentially dangerous regimens. Drugs with complex or variable dosing schemes increase risk of MRPs. Early interdisciplinary collaboration among clinical pharmacists, physicians, and nurses helps to identify and prevent potential MRPs.