The National Patient Safety Agency has sent out a warning to National Health Service staff over the “potentially fatal” consequences of administering incorrect doses of oral chemotherapy drugs to cancer patients.

The use of oral medicines to treat cancer is on the rise, with nearly 18 million doses given in hospitals and six million used in the community in England alone during 2006-7.

But three deaths and more than 400 “safety incidents” were recorded in 2003-7 in patients taking oral chemotherapies, half of which were down administration of the wrong dose, strength, frequency or quantity, the NPSA said.

In its Rapid Response Report, the Agency stresses its concern that the risk of medication error is higher if normal safeguards in place for injectable anticancer drugs are not applied when dishing out oral therapies.

Consequently, it recommends that chemotherapy is initiated by a cancer specialist, but that non-specialists who prescribe, dispense or administer oral anticancer drugs be made aware that this must be carried out and monitored to the same standard as injectable therapies, and that they have access to comprehensive protocols and treatment plans.

Furthermore, the Agency’s action plan advises that patients should be fully informed about their oral anticancer therapy – including treatment and monitoring plans - and be given contact details for specialist advice by the hospital.