Complimentary Webinar

With similar generic names and similar packaging, look-alike sound-alike errors involving Kadcyla (trastuzumab emtansine) and Herceptin (trastuzumab) are possible. ISMP Canada, in partnership with the Canadian Association of Provincial Cancer Agencies (CAPCA), invite you to participate in a one hour complimentary webinar that will provide an opportunity for participants to learn more about a global conversation taking place to identify strategies to reduce the risk of future medication errors involving these two drugs. Learning Objectives: Over the course of this one hour session participants will learn about: Near misses that have already occurred. Strategies that are being used to reduce the risk of errors occurring while using computerized prescriber order entry (CPOE) systems. How to report errors, so as to inform Health Canada as well as the World Health Organization’s International Nonproprietary Names Expert Committee. Audience: Healthcare professionals and clinical trial staff involved in the treatment of HER2-positive breast cancer; researchers developing protocols involving Kadcyla and Herceptin; pharmacy managers who oversee patient safety activities; pharmacists who dispense Kadcyla or Herceptin; nurses who administer either medication; clinical informatics personnel involved in the development or implementation of IT CPOE systems; administrators; quality and risk management personnel and those interested in patient safety in general.

Date:	Friday, June 6, 2014
Time:	9:00 am – 10:00 am PDT 10:00 am – 11:00 am MDT 11:00 am – 12:00 pm CDT 12:00 pm – 1:00 pm EDT 1:00 pm – 2:00 pm ADT 1:30 pm – 2:30 pm NDT      Time zone map
Duration:	1 hour
Cost:	Complimentary – Register Now
Presenters:	Carole Chambers, Director of Pharmacy Services (Cancer Care) Alberta Health Services Dr. Vishal Kukreti, Clinical Lead, eTools and Technology Cancer Care Ontario Heather Logan, Executive Director, Canadian Association of Provincial Cancer Agencies Kathy Vu, Clinical Lead, Safety Initiatives and Formulary Pharmacist Susan Walisser, Professional Practice Leader, BC Cancer Agency

Contact Us: webinars@ismp-canada.org

Speakers

Carole Chambers, B.Sc. (Pharm) MBA FCSHP FISOP Carole is the Pharmacy Director of Cancer Services with the Alberta Health Services, with over 50 peer reviewed publications. She serves on the provincial advisory group for pCODR and the panCanadian pricing negotiating teams. Dr. Vishal Kukreti, Clinical Lead, eTools and Technology Cancer Care Ontario Dr. Kukreti, is the Clinical Lead, eTools and Technology at Cancer Care Ontario and practising Hematologist at Princess Margaret Cancer Centre. He is an assistant professor in the Department of Medicine at the University of Toronto, and member of the Canadian Association of Provincial Cancer Agencies Systemic Therapy Safety Council. Dr. Kukreti’s research interests include patient safety and quality of care. Heather Logan, Executive Director, Canadian Association of Provincial Cancer Agencies Heather Logan is an executive leader with more than 20 years combined experience in public and health policy, cancer control, governance, media relations, and association management. Having worked in government, the Canadian not-for-profit sector, and with care delivery organizations internationally, nationally and provincially, she is connected to a broad network of health system leaders. Heather is currently the Executive Director of the Canadian Association of Provincial Cancer Agencies. Kathy Vu, Clinical Lead, Safety Initiatives and Formulary Pharmacist Kathy is the Clinical Lead, Systemic Treatment Safety Initiatives and Formulary Pharmacist at Cancer Care Ontario. She is leading provincial initiatives to improve the safe delivery of chemotherapy in the areas of incident reporting in oncology and improving the safe dispensing of oral chemotherapy. Kathy is a lecturer, facilitator and teaching associate for undergraduate and graduate programs, and frequent invited speaker. Susan Walisser, Professional Practice Leader, BC Cancer Agency Susan is the Provincial Pharmacy Professional Practice Leader at the BC Cancer Agency. She is a member of the Canadian Association of Provincial Cancer Agencies Systemic Therapy Safety Council, and BC Cancer Agency’s the Provincial Systemic Therapy Program Committee., Her practice interests include medication safety.

Background

In 2013, Health Canada approved Kadcyla as a single agent for the treatment of patients with HER2-positive, metastatic breast cancer who have received both prior treatment with Herceptin and a taxane. Herceptin is the brand name for trastuzumab (an anti-HER2 antibody), whereas Kadcyla is a HER2-targeted antibody drug conjugate, combining trastuzumab and a cytotoxic agent (derivative of emtansine). As both Herceptin and Kadcyla share an identical component in their respective generic names (trastuzumab), and both have indications for HER2+ positive metastatic breast cancer, there is a strong potential for medication errors involving these two compounds. Mix ups between these two products can lead to serious patient harm.

There have been a variety of strategies put in place to reduce the potential for errors with these two medications. In the United States, the Food and Drug Administration approved the use of the generic name, ado-trastuzumab emtansine for Kadcyla to help distinguish it from trastuzumab. Across Canada, a variety of different solutions have been put in place leading to variations as to how this drug is referred to and the loss of a global naming solution. Efforts to highlight the potential magnitude of the problem with the World Health Organization and the International Medication Safety Network have been successful but would be heightened by more data regarding near misses, incidents, risk mitigation strategies and solutions from Canada.


Related Links:

•  Health Canada Alert: Kadcyla (trastuzumab emtansine) and Herceptin (trastuzumab) - Potential Risk for Medication Error Due to Name Confusion

•  ISMP Canada Safety Bulletin: Safeguards for HYDROmorphone–Results of a Targeted Demonstration Project

•  International Medication Safety Network (IMSN): Position Statement - Making Medicines Naming, Labeling and Packaging Safer

•  Pharmaceutical company brochure:Dosing distinctions between Kadcyla and Herceptin

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