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Every day medication is administered to thousands of hospital inpatients, and medication administration errors can occur.- Interventions to reduce medication administration errors have been developed and tested; these include training, double-checking procedures, and technological solutions (such as smart infusion pumps and barcode-controlled drug administration).- Most of the studies that investigated these interventions were small, meaning it is unclear which intervention is the most effective. More research is needed to identify the best solutions.

The World Health Organization guidelines for cancer pain relief have been proven efficacious in 90% of the patients with cancer pain. The patient's self-report of pain is the focus of treatment. When initiating treatment, controlled-release preparations of opioids are generally favoured, and are combined with immediate release morphine to prevent or treat 'breakthrough' pain and to enable the optimum opioid dosage to be calculated. (Breakthrough pain is a transient increase in pain in a patient who has stable, persistent pain treated with opioids.) In patients with an unfavourable balance between analgesia and side effects, the following strategies may be useful, together with appropriate treatment of the side effects: Sequential opioid trials (so-called opioid rotation) is an approach which is effective in 50-70% of the patients. Changing the route of opioid administration is successful in 70-95% of the patients. When selecting an invasive technique, continuous subcutaneous infusion is medically preferred. Spinal analgesia is an alternative. Knowledge of the relative potency of opioid drugs and of their biologic availability is needed to guide changes in drugs or routes of administration.

Fabrikanten van medische apparatuur voor thuisgebruik zijn verplicht om een risicoanalyse te maken en duidelijke gebruikersinformatie te leveren. Bij drie medische thuiszorgtechnologieen, te weten infuus-, beademings- en dialyseapparatuur, vertonen de risicoanalyses en gebruiksaanwijzingen echter tekortkomingen. Hierdoor kan de patientveiligheid in het gedrang komen. Het is te verwachten dat de geconstateerde tekortkomingen ook voorkomen in risicoanalyses en gebruikersinformatie bij andere technologieen die thuis worden gebruikt. Dit blijkt uit onderzoek van het RIVM, in opdracht van de Inspectie voor de Gezondheidszorg. Onder andere blijkt dat in risicoanalyses vaak onvoldoende aandacht wordt besteed aan gebruiksfouten en aan risico's die zich specifiek kunnen voordoen bij gebruik thuis, waar bijvoorbeeld huisdieren bij de apparatuur kunnen komen. Daarnaast zijn risico's die de fabrikant niet volledig kan uitsluiten en die als zogeheten restrisico's in de risicoanalyse staan vermeld, vaak niet opgenomen in de gebruiksaanwijzing. Andersom komt het ook voor dat waarschuwingen in de gebruiksaanwijzing niet als risico zijn terug te vinden in de risicoanalyse. Daarnaast is geconstateerd dat de gebruiksaanwijzingen niet voldoende zijn afgestemd op gebruik van de apparatuur door patienten of mantelzorgers. Tekortkomingen hierin worden door begeleidende instellingen of ziekenhuizen doorgaans op een adequate manier opgevangen. Dit betekent echter niet dat fabrikanten zelf hiervoor minder aandacht hoeven te hebben. Verder blijkt uit procedures voor het verzamelen van praktijkervaringen dat fabrikanten dit te weinig op actieve wijze doen, bijvoorbeeld door gebruikersdagen te organiseren. In deze procedures is de rol van de distributeur (wederverkoper) vaak niet vastgelegd. Ook zijn er aanwijzingen dat niet alle incidenten in de thuissituatie bij de Inspectie voor de Gezondheidszorg worden gerapporteerd. Deze bevindingen beteken dat de "continue cyclus om producten te verbeteren" niet goed functioneert.

The World Health Organization guidelines for cancer pain relief have been proven efficacious in 90% of the patients with cancer pain. The patient's self-report of pain is the focus of treatment. When initiating treatment, controlled-release preparations of opioids are generally favoured, and are combined with immediate release morphine to prevent or treat 'breakthrough' pain and to enable the optimum opioid dosage to be calculated. (Breakthrough pain is a transient increase in pain in a patient who has stable, persistent pain treated with opioids.) In patients with an unfavourable balance between analgesia and side effects, the following strategies may be useful, together with appropriate treatment of the side effects: Sequential opioid trials (so-called opioid rotation) is an approach which is effective in 50-70% of the patients. Changing the route of opioid administration is successful in 70-95% of the patients. When selecting an invasive technique, continuous subcutaneous infusion is medically preferred. Spinal analgesia is an alternative. Knowledge of the relative potency of opioid drugs and of their biologic availability is needed to guide changes in drugs or routes of administration.

The World Health Organization guidelines for cancer pain relief have been proven efficacious in 90% of the patients with cancer pain. The patient's self-report of pain is the focus of treatment. When initiating treatment, controlled-release preparations of opioids are generally favoured, and are combined with immediate release morphine to prevent or treat 'breakthrough' pain and to enable the optimum opioid dosage to be calculated. (Breakthrough pain is a transient increase in pain in a patient who has stable, persistent pain treated with opioids.) In patients with an unfavourable balance between analgesia and side effects, the following strategies may be useful, together with appropriate treatment of the side effects: Sequential opioid trials (so-called opioid rotation) is an approach which is effective in 50-70% of the patients. Changing the route of opioid administration is successful in 70-95% of the patients. When selecting an invasive technique, continuous subcutaneous infusion is medically preferred. Spinal analgesia is an alternative. Knowledge of the relative potency of opioid drugs and of their biologic availability is needed to guide changes in drugs or routes of administration.

To determine whether intravenous home treatment with antimicrobial drugs of patients with an infection is feasible.Descriptive.Academic Hospital, Leiden, the Netherlands.In October 1992 a programme for intravenous home treatment of patients with infectious diseases was started. The programme was based on self-administration of the intravenous antibiotic therapy by the patient. The hospital pharmacy provided the antibiotics and infusion devices, an infectious diseases specialist supervised the home treatment and the nursing staff of the First Aid Department was available to change infusion cannulas. After assessment of their medical and psychosocial fitness in which the general practitioner was involved, thorough instruction on use of the infusion device and care of the infusion cannula, patients were sent home.In the period October 1992-September 1996, 162 patients (median age: 45.0 years (range: 3-82)) were treated at home for a median period of 15 days (1-221). Osteomyelitis, arthritis, Lyme disease, septicaemia with secondary foci, and herpes virus infections were the most frequent indications for home treatment. Penicillins and cephalosporins were given in 70% of the cases, teicoplanin and antiviral drugs in 12% and 14%, respectively. For intermittent administration bolus injection, a mechanical or elastomeric pump were used, for continuous infusion a syringe or cassette pump. The intention of the programme that the patient performed the home treatment as much as possible without extra professional help, was realised in 82% of the patients. In 60% of the cases the patients were fully self supporting, in 22% family or friends played an important role.Home treatment with antimicrobial drugs intravenously is quite feasible. If this were fully implemented, about 1400 patients in the Netherlands could be treated in this manner.

Doel. Nagaan of thuisbehandeling met antimicrobiële middelen van patiënten met een infectie mogelijk is. Opzet. Descriptief. Plaats. Academisch Ziekenhuis Leiden. Methode. In oktober 1992 werd begonnen met het thuis behandelen van patiënten met intraveneus toegediende antimicrobiële middelen. Bij de thuisbehandeling diende de patiënt zichzelf de geneesmiddelen toe. De ziekenhuisapotheek leverde de medicatie en de infusiehulpmliddelen. Een internist-infectioloog had de supervisie over de thuisbehandeling en de verpleegkundigen van de eerstehulpafdeling, en de poliklinieken wisselden zo nodig infusiecanules. Patiënten mochten naar huis nadat in overleg met de huisarts de medische en psychosociale geschiktheid was beoordeeld en nadat instructie had plaatsgevonden over de infusietechniek en de zorg voor de infusiecanule. Resultaten. In de periode oktober 1992-september 1996 werden 162 patiënten thuis behandeld; de mediane leeftijd was 45 jaar (uitersten: 3-82) en de mediane duur van de thuisbehandeling 15 dagen (1-221). Osteomyelitis, artritis, ziekte van Lyme, sepsis met strooihaarden en infecties met herpesvirussen waren de meest voorkomende indicaties voor thuisbehandeling. Penicillinen en cefalosporinen werden bij 70, teicoplanine bij 12 en antivirale middelen bij 14 van de behandelingen gegeven. Voor intermitterende toediening werden voornamelijk injectiespuit, veerdrukpomp of elastomeerpomp gebruikt; voor continue infusie spuitenpomp of cassettepomp. Het plan om de patiënt de thuisbehandeling zoveel mogelijk zonder extra professionele hulp te laten uitvoeren werd bij 82 van de behandelingen verwezenlijkt. In 60 van de gevallen voerden de patiënten de thuisbehandeling uit zonder verdere hulp, in 22 van de gevallen vervulde mantelzorg een essentiële rol. Conclusie. Thuisbehandeling met antimicrobiële middelen intraveneus is goed mogelijk. Bij algehele invoering zouden circa 1400 patiënten per jaar daarvan gebruik kunnen maken.

Doel. Nagaan of thuisbehandeling met antimicrobiële middelen van patiënten met een infectie mogelijk is. Opzet. Descriptief. Plaats. Academisch Ziekenhuis Leiden. Methode. In oktober 1992 werd begonnen met het thuis behandelen van patiënten met intraveneus toegediende antimicrobiële middelen. Bij de thuisbehandeling diende de patiënt zichzelf de geneesmiddelen toe. De ziekenhuisapotheek leverde de medicatie en de infusiehulpmliddelen. Een internist-infectioloog had de supervisie over de thuisbehandeling en de verpleegkundigen van de eerstehulpafdeling, en de poliklinieken wisselden zo nodig infusiecanules. Patiënten mochten naar huis nadat in overleg met de huisarts de medische en psychosociale geschiktheid was beoordeeld en nadat instructie had plaatsgevonden over de infusietechniek en de zorg voor de infusiecanule. Resultaten. In de periode oktober 1992-september 1996 werden 162 patiënten thuis behandeld; de mediane leeftijd was 45 jaar (uitersten: 3-82) en de mediane duur van de thuisbehandeling 15 dagen (1-221). Osteomyelitis, artritis, ziekte van Lyme, sepsis met strooihaarden en infecties met herpesvirussen waren de meest voorkomende indicaties voor thuisbehandeling. Penicillinen en cefalosporinen werden bij 70, teicoplanine bij 12 en antivirale middelen bij 14 van de behandelingen gegeven. Voor intermitterende toediening werden voornamelijk injectiespuit, veerdrukpomp of elastomeerpomp gebruikt; voor continue infusie spuitenpomp of cassettepomp. Het plan om de patiënt de thuisbehandeling zoveel mogelijk zonder extra professionele hulp te laten uitvoeren werd bij 82 van de behandelingen verwezenlijkt. In 60 van de gevallen voerden de patiënten de thuisbehandeling uit zonder verdere hulp, in 22 van de gevallen vervulde mantelzorg een essentiële rol. Conclusie. Thuisbehandeling met antimicrobiële middelen intraveneus is goed mogelijk. Bij algehele invoering zouden circa 1400 patiënten per jaar daarvan gebruik kunnen maken.

A 25-year-old male with idiopathic chronic pancreatitis suffered from severe pain not reacting to medical therapy. Intractable pain persisted after the following procedures: subtotal resection of the pancreas, interpleural administration of bupivacaine, epidural administration of bupivacaine, and thoracoscopic sympathectomy. Eventually, adequate pain relief was achieved with intrathecal administration of morphine and bupivacaine. An infusion pump, externally controlled by radiotelemetry, was implanted subcutaneously for intrathecal drug administration. With this pump the patient was fully ambulant. Intrathecal administration of morphine and bupivacaine through an implanted pump is a possible new technique for pain management in chronic pancreatitis.

Assessment of intravenous home treatment of respiratory infections of cystic fibrosis (CF) patients.Provinces Groningen, Drente, Friesland and Overijssel.Open study.Eleven CF patients, aged 10 to 28 years participated. Thirty episodes of home i.v. treatment with antibiotics were arranged. Differences in vital capacity (VC) and forced expiratory volume in one second (FEV1) and in body weight before and after treatment were compared with the same variables obtained during hospitalisation in the year before they were treated at home. Adverse events during home treatment were recorded.No differences were noted in changes in VC, FEV1 and body weight between home and hospital treatments. During 30 episodes of home treatment a new intravenous catheter had to be implanted only twice.In these 11 patients, intravenous treatment of respiratory infections at home was as efficacious as in hospital. No serious adverse events were observed.

Thirty-seven patients with liver metastases from colorectal cancer were treated with hepatic arterial infusion of 5-FU. Before therapy an arterial access device (Port-A-Cath) was implanted. Treatment was given on an outpatient basis with a portable infusion pump. 5-FU was administered as a continuous infusion at a dose of 1000 mg/sq.m. per day during 5 or 6 days. Cycles were repeated every three weeks. In 12 (37.5%) of the 32 evaluable patients a partial remission was achieved. Median duration of remission was 11 months and median duration of survival was 16 months. Side effects of chemotherapy were usually mild. In 11 patients thrombosis of the hepatic artery was observed, occurring after a median period of 5 months after implantation of the access device. Further study is required to improve the treatment results in this disease with its unfavourable prognosis.

To record the daily morphine doses, the influence of the treatment on quality of life and the incidence of side-effects and complications of continuous intrathecal morphine administration.Academic Hospital, Free University, Amsterdam.Prospective.Forty terminal patients with intractable cancer pain, who had either insufficient pain relief or severe side effects from systemic analgesics were selected for continuous intrathecal administration of morphine. An intrathecal catheter was implanted, tunnelled and connected with a portable infusion pump delivering morphine constantly and if needed on demand. In a pain diary the patients recorded: the number of daily doses of morphine, concomitant medication, pain scores on a visual analogue scale (VAS), extra doses and activities.The total number of catheter days was 1486. Patients were treated for a mean of 37.2 (range 2-183) days. The mean dose of daily administered morphine was in 30 patients (75%) less than 20 mg. Sufficient pain relief (VAS score5) was achieved in 37 patients (92.5%). Three patients had pain due to spinal cord compression, hardly responding to intrathecal morphine. Withdrawal symptoms, post-puncture headache and leakage of fluid could been treated conservatively. The catheter was removed inadvertently 6 times and could be replaced on outpatient basis. Meningitis occurred in 2 patients, who were adequately treated with antibiotics. The catheter could be re-inserted within 10 days.In terminally ill cancer patients, the continuous intrathecal administration of morphine may be recommended if conventional pain relief fails.

A study to evaluate the feasibility and toxicity of outpatient continuous intravenous infusion of fluorouracil (5-FU) was initiated at the department of Medical Oncology of the University Hospital of Utrecht. To this purpose a subcutaneous drug delivery system (Port-a-Cath) was implanted in 36 patients with various advanced cancers. Of these patients 83% had received prior chemotherapy (including 5-FU in 62%). Ambulatory continuous-infusion pumps were used to administer 5-FU in a dosage of 300 mg/m2/24 h. The treatment was continued until tumour progression was seen, and it was interrupted in case of toxicity grade 2 or more (WHO criteria). A Port-a-Cath was implanted 37 times in the 36 patients. The main complications of this infusion system were pneumothorax (2/37), arrhythmia (1/37), catheter sepsis (2/37) and thrombosis (2/37); they were easily managed. The toxicity and feasibility of this treatment were evaluable in 30 patients. They received a median of 44 g 5-FU (range 11-136, 5 g, mean 281 mg/m2/24 h) during a median infusion time of 12 weeks (range 4-32 w). Side effects were encountered in 70% of the patients and consisted of the hand-foot syndrome (14/30), nausea and vomiting (8/30), diarrhoea (8/30) and stomatitis (7/30). The toxicity was completely reversible after a short interruption of the chemotherapy. The treatment was tolerated well, and good palliation was attained in 22 of 30 patients. The best response was seen in patients with colon and breast cancer. We conclude that continuous infusion of 5-FU is a reliable outpatient chemotherapy even in this category of patients.

This review describes the role of central venous catheters (CVC's) in the treatment of cancer. Indications and contra-indications for CVC-insertion, CVC-care, their complications, prevention and management are discussed. Totally implantable CVC's have been compared with Hickman-Broviac catheters to facilitate an adequate choice for an individual patient. Both CVC-types showed a similar and low number of complications, provided staff and patients are well instructed and given good care. In such cases infection and thrombosis occur in less than 3-5% of nowadays CVC's. The CVC proved to be useful and safe in cancer treatment and should not be withheld when the patient lacks, or will probably lack within a short time an adequate venous access.