I'm hoping you can help provide some corrective actions based on an error we had:

A patient with ongoing rejection of kidney transplant was receiving filgrastim. Once the white count improved the team had asked for the filgrastim to be discontinued (was getting it 2x/week) and it was not recognized that it was not actually discontinued.
The patient went on to receive two more doses and ultimately the WBC count rose to 59K

Events:
Sunday: WBC count 9k after filgrastim-->should have been discontinued as per team
Thursday: WBC count 4k and filgrastim given erroneously because order never d/c'd
Friday: WBC count 26k
Sunday: WBC count 18K and another filgrastim dose erroneously given because order was still active
Monday: WBC count 59K

We tossed around the idea of building hold parameters into the order but our oncology department feels like this would lead to more errors as plans often change.

Any thoughts on what you would do or what you currently do surrounding this medication?

Thanks for your time,