Direct provider feedback to decrease chemotherapy ordering errors: the "gray envelope" initiative

Abstract

Chemotherapy errors are the second leading cause of mortality related to medication errors. Most medication errors occur in the provider ordering process. We evaluated the rate of chemotherapy ordering errors in our center and designed an intervention to decrease the rate of ordering errors. The intervention focused on direct confidential written feedback to the providers. Our intervention resulted in a significant decrease in ordering errors from 7% pre-intervention to 3.9% post intervention (P < 0.001). We conclude that direct written provider feedback can result in a significant decrease in chemotherapy ordering errors.