Ten simple strategies to prevent chemotherapy errors

Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses

BACKGROUND

The prevalence of medication errors associated with chemotherapy administration is not precisely known. Little evidence exists concerning the extent or nature of errors; however, some evidence demonstrates that errors are related to prescribing. This article demonstrates how the review of chemotherapy orders by a designated nurse known as a verification nurse (VN) at a National Cancer Institute-designated comprehensive cancer center helps to identify prescribing errors that may prevent chemotherapy administration mistakes and improve patient safety in outpatient infusion units.

OBJECTIVES

This article will describe the role of the VN and details of the verification process.

METHODS

To identify benefits of the VN role, a retrospective review and analysis of chemotherapy near-miss events from 2009-2014 was performed.

FINDINGS

A total of 4,282 events related to chemotherapy were entered into the Reporting to Improve Safety and Quality system. A majority of the events were categorized as near-miss events, or those that, because of chance, did not result in patient injury, and were identified at the point of prescribing.

Shift change handovers and subsequent interruptions: potential impacts on quality of care

OBJECTIVES

Two statistical surveys in France revealed both widespread dissatisfaction about shift change handovers and the feeling of being frequently disturbed by interruptions. Shift change handovers (SCHs) are being reduced or eliminated in France to reduce staff costs. The objective of our study is to clarify the consequences of short SCHs on efficiency, team function, and quality of care.

METHODS

Real-time task ergonomic analysis of 29 state-registered nurses (RNs), 18 nursing aides (NAs), and 14 full-time physicians was conducted in various departments of general and university hospitals.

RESULTS

The average time available to RNs for sharing information during SCHs was 15 minutes at the beginning of the work session and 13 minutes at the end. There were, on average, 50 interruptions of activity, and these interruptions occupied 16% of the working time. Consequently, less time was available for direct care, although the number of such acts was increased. Periods for preparation of care, writing, seeking information, or equipment were very numerous. The mean number of changes of activity was very large: 260 per work session. For NAs, SCHs were similar to those for RNs at the beginning of the work session (mean = 18 minutes) but shorter at the end (10 minutes). The mean number of interruptions was 30 and caused 10.3% of the working time to be lost with 164 changes of activity. For physicians, SCHs were even shorter and, in many cases, nonexistent. The mean number of interruptions was 30 (11.4% of their working time, 153 changes of activity). Shift change handovers were mostly conducted separately for RNs, NAs, and physicians.

DISCUSSION

A better sharing of knowledge between the different health-care workers, and especially at the beginning of the work session, could reduce interruptions and potentially improve quality of care.

Quality performance improvement with the implementation of standard chemotherapy order forms

PURPOSE

Before October 2000, physicians in our institution handwrote chemotherapy orders on blank order sheets. There was no standard to which the physician could include variables that were crucial to the completeness of a chemotherapy order. For this reason, chemotherapy orders were frequently incomplete and had to be adjusted by the pharmacist after discussing the missing variables with the ordering physician. As a part of our goal to minimize errors, standard chemotherapy forms were initiated at our institution in October 2000.

METHODS

The first standard form implemented was a written order form that constituted a standard of the ideal variables necessary to accurately complete chemotherapy orders. These variables were the diagnosis, regimen, height, weight, body surface area (BSA), route, frequency, duration and chemotherapy dose and calculation based upon BSA. The next updated form was an electronic version similar to the original, and was implemented in April 2002.

RESULTS

From February 1999 to March 2000, using the traditional unstandardized blank order sheets, the average order completeness was 45%. After the standard written forms were introduced, from October 2000 to March 2002, the average chemotherapy order completeness was 81%, an improvement of 36%. Completeness improved to an average of 93% from April 2002 to December 2003, after the implementation of the electronic chemotherapy form.

CONCLUSION

Chemotherapy order completeness improves considerably through the standardization of chemotherapy order forms. The electronic forms show an additional improvement over handwritten forms. Electronic standardization of chemotherapy forms should be adopted as a best-practice model in hematology-oncology practices throughout the country.

Guideline adherence to chemotherapy administration safety standards: a survey on nurses in a single institute

Objective

Little is known about the guideline adherence of nurses to chemotherapy administration guidelines. We determined the guideline adherence of nurses to the Chemotherapy Administration Safety Standards and the relationship between demographic characteristics and guideline adherence.

Methods

Survey sheets containing two questions on demographic characteristics and 16 questions on the guideline adherence of nurses regarding chemotherapy administration were distributed to all in-patient departments in our hospital in which chemotherapy was performed. All clinical nurses in the department were recommended to respond.

Results

Of 202 nurses, 123 responses were collected (61% response rate). The guideline adherence rate was >70% for 15 of 16 questions, but 55% of respondents indicated that there was no competency monitoring for nurses. Nurses with >7 years of clinical nursing experience felt more competent in performing cardiopulmonary resuscitation (CPR) than nurses with <7 years of clinical nursing experience (p=0.032).

Conclusion

The guideline adherence rate of nurses with respect to chemotherapy administration was high, with the exception of the absence of a competency monitoring for nurses. A significant number of nurses with <7 years of clinical nursing experience felt incompetent in performing CPR.

American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards

Standardization of care can reduce the risk of errors, increase efficiency, and provide a framework for best practice. In 2008, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) invited a broad range of stakeholders to create a set of standards for the administration of chemotherapy to adult patients in the outpatient setting. At the close of a full-day structured workshop, 64 draft standards were proposed. After a formal process of electronic voting and conference calls, 29 draft standards were eliminated, resulting in a final list of 35 draft measures. The proposed set of standards was posted for 6 weeks of open public comment. Three hundred twenty-two comments were reviewed by the Steering Group and used as the basis for final editing to a final set of standards. The final list includes 31 standards encompassing seven domains, which include the following: review of clinical information and selection of a treatment regimen; treatment planning and informed consent; ordering of treatment; drug preparation; assessment of treatment compliance; administration and monitoring; assessment of response and toxicity monitoring. Adherence to ASCO and ONS standards for safe chemotherapy administration should be a goal of all providers of adult cancer care.

American Society Of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards

Standardization of care can reduce the risk of errors, increase efficiency, and provide a framework for best practice. In 2008, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) invited a broad range of stakeholders to create a set of standards for the administration of chemotherapy to adult patients in the outpatient setting. At the close of a full-day structured workshop, 64 draft standards were proposed. After a formal process of electronic voting and conference calls, 29 draft standards were eliminated, resulting in a final list of 35 draft measures. The proposed set of standards was posted for 6 weeks of open public comment. Three hundred twenty-two comments were reviewed by the Steering Group and used as the basis for final editing to a final set of standards. The final list includes 31 standards encompassing seven domains, which include the following: review of clinical information and selection of a treatment regimen; treatment planning and informed consent; ordering of treatment; drug preparation; assessment of treatment compliance; administration and monitoring; and assessment of response and toxicity monitoring. Adherence to ASCO and ONS standards for safe chemotherapy administration should be a goal of all providers of adult cancer care.

The impact of computerized prescribing on error rate in a department of Oncology/Hematology

AIMS

A comparison of prescribing errors detected for computerized and spreadsheet prescriptions in the Department of Hematology and Oncology of the Norfolk and Norwich University hospital.

METHODS

A prospective audit of 1941 prescriptions for chemotherapy was made from January to September 2005. Each new cycle of chemotherapy ordered was monitored for prescribing errors, which were analyzed by method of prescription (computerized or spreadsheet), prescriber, type, and severity.

RESULTS

Computerized prescribing reduced errors by 42% (RR 0.58; 95% CI 0.47-0.72). Errors occurred in 20% of spreadsheet prescriptions compared with 12% of the computerized prescriptions. There was a significant difference in error rates of three different prescribers whichever prescribing system was used. The proportion of errors that were minor was reduced and serious was increased with little change in the proportion of significant or life-threatening errors.

CONCLUSIONS

The impact of computerized prescribing on adverse drug events requires further evaluation. Prescriber training may be important in further reducing errors. The implementation of all the existing functions of the electronic system should lead to further reduction in errors.

Impact of computerised chemotherapy prescriptions on the prevention of medication errors

OBJECTIVES

The authors sought to evaluate the impact of computerised chemotherapy prescription on the reduction of medication errors. The purpose of this study was to assess the incidence of errors present in electronic versus manual prescription.

MATERIAL AND METHODS

The data gathered from computerised chemotherapy prescription sheets were submitted to a prospective analysis as cases of the intervention groups. The control group was comprised of the handwritten chemotherapy prescription sheets. Chemotherapy prescriptions for consecutive oncology patients were analysed by 2 independent examiners, who investigated errors of omission, commission, interpretation of dates, abbreviations and illegible handwriting. The proportion of treatment prescriptions containing one or more errors and the median of errors were calculated in order in both groups.

RESULTS

At least one error was detected in 100% of the manual prescriptions and in 13% of computerised prescriptions (p < 0.001). The median of errors per computerised prescription was 0 (range: 0- 1), whereas in manual prescriptions the median was 5 (range: 1-12) (p < 0.001). Errors of omission were predominant in manual prescriptions. Errors of commission were limited to 1 case of unjustified cytostatic agent infra-dosage in a computerised prescription. This error was present in 3 cases in handwritten prescriptions and, in addition, 1 case of premedication drug substitution was detected. Errors of interpretation of the date, use of abbreviations and illegible handwriting were frequent among manual prescriptions and were absent from computerised prescriptions.

CONCLUSIONS

Electronic chemotherapy prescription is a powerful tool. In this study it has been shown to decrease chemotherapy-related medication errors and ensure that safe chemotherapy practices were followed.

Oral chemotherapy safety practices at US cancer centres: questionnaire survey

OBJECTIVE

To characterise current safety practices for the use of oral chemotherapy.

DESIGN

Written questionnaire survey of pharmacy directors of cancer centres.

SETTING

Comprehensive cancer centres in the United States.

RESULTS

Respondents from 42 (78%) of 54 eligible centres completed the survey, after consulting with 89 colleagues. Clinicians at 29 centres used handwritten prescriptions, two used preprinted paper prescriptions, and six used electronic systems for most oral chemotherapy prescribing. For six commonly used oral chemotherapies, on average 10 centres required a diagnosis on the prescription, 11 required the protocol number, four required the cycle number, nine required double checking by a second clinician, 14 required a calculation of body surface area, and 14 required a calculation of dose per square metre of body surface area. Only a third of centres requested patients' written informed consent when oral chemotherapy was given off protocol. Nearly a quarter (10) of centres had no formal process for monitoring patients' adherence. In the past year respondents at 10 centres reported at least one serious adverse drug event related to oral chemotherapy, and respondents at 13 centres reported a serious near miss.

CONCLUSION

Few of the safeguards routinely used for infusion chemotherapy have been adopted for oral chemotherapy at US cancer centres. There is currently no consensus at these centres about safe medication practices for oral chemotherapy.