Improving the cancer chemotherapy use process

Comparison of IV oncology infusions compounded via robotics and gravimetrics-assisted workflow processes

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Purpose

A study was conducted to compare an intravenous (IV) gravimetric technology–assisted workflow (TAWF) platform to an IV robotic system. In the study we reviewed both IV technology platforms using the same gravimetric quality assurance system, which allowed for direct comparison.

Methods

All oncology preparations compounded from January 2016 through December 2018 using either system were included in our retrospective analysis. Final preparation accuracy, IV system precision, and workflow throughput (analyzed using lean process methodologies) were evaluated.

Results

Data analysis indicated that use of the IV gravimetric TAWF system was associated with a significantly lower percentage of accuracy errors compared to the IV robotics system (1.58% vs 2.47%, P < 0.001), with no significant difference in absolute precision (1.12 vs 1.12 P = 0.952). Lean analysis demonstrated that overall completion time (17:49 minutes vs 24:45 minutes) and compound preparation time (2:39 minutes vs 6:07 minutes) were less with the IV gravimetric TAWF vs the IV robotics system.

Conclusion

Implementation of either an IV gravimetric TAWF system or IV robotics system will result in similar compounding accuracy and precision. Preparation time was less with use of the IV gravimetric TAWF vs the IV robotic system, but the IV robotic system required less human intervention. Both systems ensure medication safety for patients, although the IV robotic system has increased safeguards in place. Therefore, the primary driver for implementing these systems is alternative factors such as cost of systems implementation and maintenance, employee safety, and drug waste.

Harmonization of Busulfan Plasma Exposure Unit (BPEU): A Community-Initiated Consensus Statement

Busulfan therapeutic drug monitoring (TDM) is often used to achieve target plasma exposures. Variability in busulfan plasma exposure units (BPEU) is a potential source for misinterpretation of publications and protocols and is a barrier to data capture by hematopoietic cell transplantation (HCT) registry databases. We sought to harmonize to a single BPEU for international use. Using Delphi consensus methodology, iterative surveys were sent to an increasing number of relevant clinical stakeholders. In survey 1, 14 stakeholders were asked to identify ideal properties of a BPEU. In survey 2, 52 stakeholders were asked (1) to evaluate BPEU candidates according to ideal BPEU properties established by survey 1 and local position statements for TDM and (2) to identify potential facilitators and barriers to adoption of the harmonized BPEU. The most frequently used BPEU identified, in descending order, were area under the curve (AUC) in μM × min, AUC in mg × h/L, concentration at steady state (Css) in ng/mL, AUC in μM × h, and AUC in μg × h/L. All respondents conceptually agreed on the ideal properties of a BPEU and to adopt a harmonized BPEU. Respondents were equally divided between selecting AUC in μM × min versus mg × h/L for harmonization. AUC in mg × h/L was finally selected as the harmonized BPEU, because it satisfied most of the survey-determined ideal properties for the harmonized BPEU and is read easily understood in the clinical practice environment. Furthermore, 10 major professional societies have endorsed AUC in mg × h/L as the harmonized unit for reporting to HCT registry databases and for use in future protocols and publications.

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology

Purpose

To update the American Society of Clinical Oncology (ASCO)/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology.

Methods

The ASCO/ONS Chemotherapy Administration Safety Standards were first published in 2009 and updated in 2011 to include inpatient settings. A subsequent 2013 revision expanded the standards to include the safe administration and management of oral chemotherapy. A joint ASCO/ONS workshop with stakeholder participation, including that of the Association of Pediatric Hematology Oncology Nurses and American Society of Pediatric Hematology/Oncology, was held on May 12, 2015, to review the 2013 standards. An extensive literature search was subsequently conducted, and public comments on the revised draft standards were solicited.

Results

The updated 2016 standards presented here include clarification and expansion of existing standards to include pediatric oncology and to introduce new standards: most notably, two-person verification of chemotherapy preparation processes, administration of vinca alkaloids via minibags in facilities in which intrathecal medications are administered, and labeling of medications dispensed from the health care setting to be taken by the patient at home. The standards were reordered and renumbered to align with the sequential processes of chemotherapy prescription, preparation, and administration. Several standards were separated into their respective components for clarity and to facilitate measurement of adherence to a standard.

Conclusion

As oncology practice has changed, so have chemotherapy administration safety standards. Advances in technology, cancer treatment, and education and training have prompted the need for periodic review and revision of the standards. Additional information is available at http://www.asco.org/chemo-standards.

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology

Purpose

To update the ASCO/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology.

Methods

The ASCO/ONS Chemotherapy Administration Safety Standards were first published in 2009 and updated in 2011 to include inpatient settings. A subsequent 2013 revision expanded the standards to include the safe administration and management of oral chemotherapy. A joint ASCO/ONS workshop with stakeholder participation, including that of the Association of Pediatric Hematology Oncology Nurses and American Society of Pediatric Hematology/Oncology, was held on May 12, 2015, to review the 2013 standards. An extensive literature search was subsequently conducted, and public comments on the revised draft standards were solicited.

Results

The updated 2016 standards presented here include clarification and expansion of existing standards to include pediatric oncology and to introduce new standards: most notably, two-person verification of chemotherapy preparation processes, administration of vinca alkaloids via minibags in facilities in which intrathecal medications are administered, and labeling of medications dispensed from the health care setting to be taken by the patient at home. The standards were reordered and renumbered to align with the sequential processes of chemotherapy prescription, preparation, and administration. Several standards were separated into their respective components for clarity and to facilitate measurement of adherence to a standard.

Conclusion

As oncology practice has changed, so have chemotherapy administration safety standards. Advances in technology, cancer treatment, and education and training have prompted the need for periodic review and revision of the standards. Additional information is available at http://www.asco.org/chemo-standards .

Advancing the Future of Patient Safety in Oncology: Implications of Patient Safety Education on Cancer Care Delivery

Emerging challenges in health care delivery demand systems of clinical practice capable of ensuring safe and reliable patient care. Oncology in particular is recognized for its high degree of complexity and potential for adverse events. New models of student education hold promise for producing a health care workforce armed with skills in patient safety. This training may have a particular impact on risk reduction in cancer care and ultimately improve clinical performance in oncology. A 1-day student program focused on the principles of patient safety was developed for the third-year medical school class. The core curriculum consisted of an online patient safety module, root cause analyses of actual patient safety events, and simulation scenarios designed to invoke patient safety skills. The program was successfully implemented and received an average of 4.2/5 on evaluations pertaining to its importance and effectiveness. Student surveys demonstrated that 59 % of students were not previously aware of system-based approaches to improving safety, 51 % of students had witnessed or experienced a patient safety issue, while only 10 % reported these events. Students reported feeling more empowered to act on patient safety issues as a result of the program. Educational programs can provide medical students with a foundation for skill development in medical error reduction and help enhance an organization's culture of safety. This has the potential to reduce adverse events in complex patient care settings such as clinical oncology.

Updating a survey for medication error prevention

Objective. Literature review and subsequent gap analysis of the current Alberta Cancer Board (ACB) Oncology Medication Error Prevention Status Survey and the incorporation of new information to aid in the development of a stronger medication error prevention system.

Design. Gap analysis based on a literature review was performed on the current ACB survey via a literature search of EMBASE, Medline, and the Cochrane Database of Systematic Reviews. The completed survey was sent to 17 ACB sites for feedback.

Setting. The ACB in the Canadian province of Alberta, which includes 2 public tertiary centers and 15 associated community satellite sites based around the province in existing hospitals.

Main outcome measures. Gaps in the current medication error prevention survey requiring improvement as compared to current literature, with emphasis on pharmacy.

Results. All sections required additional information and two new sections were created to reduce the gaps in organizational commitment and environmental concerns. Of the 17 ACB sites, 13 sites responded to the survey and 11 responded to the questionnaire. Out of a possible 154 questions, 64 questions had at least one site disagree and 20 questions had more than one site disagree.

Conclusion. Through a literature review and gap analysis, the current ACB Oncology Medication Error Prevention Status Survey was improved. Responses to changes have not only demonstrated the need for a survey of this kind, but also the need for periodic updates of the information in the survey.

Pharmacy Technician Competencies for Practice in an Oncology Pharmacy

Objective:

To document the additional competencies that a well-trained pharmacy technician, with no previous oncology pharmacy training or experience, needs to practice effectively in an oncology pharmacy; and to develop a form to document the training of oncology pharmacy technicians at our institution.

Design:

From September 1, 1997, to November 1, 1997, the oncology pharmacist and the oncology pharmacy technicians developed a list of pharmacy technician competencies that were believed to be unique to pharmacy technician practice in an oncology pharmacy. Information from MEDLINE searches, drug manufacturer materials, and reference books was used to support the competencies identified.

Setting:

This project was conducted at Brooke Army Medical Center, a 450-bed teaching and research institution of the US Army Medical Department.

Results:

Twenty-five oncology pharmacy technician competencies were documented. This list was made into a form for inclusion in each oncology pharmacy technician's competency-based assessment folder and for use in training of future oncology pharmacy technicians.

Conclusions:

There are a significant number of additional competencies that a well-trained pharmacy technician needs in order to practice effectively in our institution's oncology pharmacy. The identification of these additional competencies facilitated the development of a form to document the training of oncology pharmacy technicians.

The impact of introducing pre-printed chemotherapy medication charts to a day chemotherapy unit

Context. The cytotoxic regimens used in the contemporary day chemotherapy unit are often complicated and present numerous opportunities for error, inadvertent misadventure in prescription orders and variations in drug administration. The introduction of pre-printed chemotherapy charts for each protocol was introduced to minimise incorrect or incomplete prescribing by medical staff.

Objective. To assess the benefits of introducing pre-printed chemotherapy charts into a day chemotherapy unit.

Method. Commonly used protocols in the unit were assessed and assembled into pre-printed chemotherapy charts. The doses and administration details of each protocol were reviewed by chemotherapy nursing staff, medical staff and the oncology pharmacist before the charts were finalised. Clinical interventions performed by the oncology pharmacist were recorded for 1 month prior and 1 month following the introduction of the pre-printed charts. Nursing and medical staff were surveyed on their level of satisfaction with the pre-printed chemotherapy charts.

Results. Prior to the introduction of the pre-printed charts, 74% of chemotherapy charts were problematic requiring multiple pharmacy interventions per chart. After the introduction of the pre-printed charts, 43% of charts were problematic requiring an average of one pharmacy intervention per chart. Pharmacy interventions were significantly reduced, which has resulted in a significant reduction in workload for the oncology pharmacist. The medical and nursing staff strongly supported the introduction of the pre-printed charts. There has been a reduction in the variation of orders amongst medical officers, reduction in prescribing errors, decreased anxiety amongst staff and better work-flow in the Day Chemotherapy Unit.

Conclusion. Pre-printed chemotherapy medication charts have promoted a more methodical approach to the prescribing and administration of chemotherapy, which has resulted in a more efficient day chemotherapy unit.

Extending the Quality and Safety Agenda From Parenteral to Oral Chemotherapy

This article describes some of the steps that can be taken across the entire oral chemotherapy journey to improve quality and safety by leveraging existing and emerging tools.

Learning from disaster: patient safety and the role of oncology nurses

When the Oncology Nursing Society (ONS) was almost exactly half its present age, in November 1994, a Boston Globe health columnist named Betsy Lehman was admitted to the Dana-Farber Cancer Institute in Boston, Massachusetts, to receive an investigational regimen for breast cancer. Her treatment ended in disaster. In one of the most notorious patient safety failures of modern times, Lehman was given severe overdoses of cyclophosphamide during a four-day period. On each of those four days, nurses, physicians, and pharmacists at Dana-Farber failed to notice that Lehman was receiving doses four times greater than the intended amount (Aspden, Wolcott, Bootman, & Cronenwett, 2007). Lehman died of cyclophosphamide toxicity on December 3, 1994.
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Infusional chemotherapy and medication errors in a tertiary care pediatric cancer unit in a resource-limited setting

BACKGROUND

Drug administration is a multiprofessional process. The high toxicity and low therapeutic index of chemotherapy drugs make medication errors a significant problem, resulting in excessive patient morbidity and cost.

OBJECTIVE

An audit of the delivery of infusional chemotherapy among pediatric inpatients was planned, with the objective of improving practice and minimizing errors.

METHOD

An observational study was conducted between January and August 2012. Patients were followed up from their premedication until the completion of postchemotherapy hydration and/or rescue drugs. Errors were recorded and classified by error type, cause, severity, unit location, medication involved, and harm caused.

RESULTS

A total of 205 observations were made and 23(13.6%) errors recorded, of which 6 were intercepted. No life-threatening adverse drug event was recorded. The most important risk factor predisposing to errors was admission to nonpediatric ward (P=0.004). Documentation errors and incorrect infusion time were the 2 most common errors, whereas the most frequent error node was administration error. Appropriate steps were taken to prevent their reoccurrence.

CONCLUSIONS

This study helped provide important information about the rate and epidemiology of medication errors, emphasizing on the role of audit in enabling development of appropriate error-reducing strategies, particularly in the context of quality assurance in hospitals.

Development of a policy and procedure for accidental chemotherapy overdose

A policy regarding rapid response to chemotherapy overdoses was developed by the authors in an attempt to minimize morbidity and mortality. The parameters of a chemotherapy overdose were defined to promote early recognition of an overdose incident. Resources needed to guide potential therapeutic interventions and required monitoring were developed. The policy defines the immediate actions to be taken in the event of a chemotherapy overdose. The availability of a chemotherapy overdose policy provides an enhanced level of safety for patients by ensuring that appropriate treatment is initiated without delay. The development of the policy was in response to the reporting of a tragic error at another institution. Healthcare providers must recognize and address potential areas of vulnerability to maximize patient safety.

Evaluating an oncology systemic therapy computerized physician order entry system using international guidelines

Chemotherapy is prone to medication error resulting from complexities in ordering and administration. Computerized physician order entry (CPOE) has been established as an important tool to minimize such errors and hence improve patient safety. As a leading Canadian advisory body in oncology, Cancer Care Ontario (CCO) has been a champion in developing and implementing its own cancer systemic therapy CPOE, the Oncology Patient Information System (OPIS). This article reviews and consolidates principles for oncology CPOE systems as found in the literature and in guidelines created by three international oncology organizations (American Society of Clinical Oncology, Clinical Oncological Society of Australia, and CCO). It then evaluates OPIS by these standards and provides a working example of what a cancer CPOE system should look like. This document can therefore be used as a framework to help develop and evaluate cancer CPOE platforms in different national settings. As end users, oncologists are considered key stakeholders in developing such systems and thus should be well informed about CPOE principles to help make decisions on the appropriate implementation of these platforms in their local practice settings. In addition, oncologists are also important champions for the successful uptake of oncology CPOE platforms and would benefit from a better understanding of whether proposed or existing local CPOE systems meet established standards.

Study of medication errors on a community hospital oncology ward

PURPOSE

Medication errors (MEs) have been a significant problem resulting in excessive patient morbidity and cost, especially for cancer chemotherapeutic agents. Although some progress has been made, ME measurement methods and prevention strategies remain important areas of research.

METHODS

During a 2-year period (2003-2004), we conducted a prospective study on the oncology ward of a large community hospital, with the goals of (1) complete nurse reporting of observed medication administration errors (MAEs), (2) classifying observed MAEs, and (3) formulating improvement strategies. We also conducted a retrospective review of a randomly chosen sample of 200 chemotherapy orders to assess the appropriateness of ordering, dispensing, and administration.

RESULTS

Our nurses reported 141 MAEs during the study period, for a reported rate of 0.04% of medication administrations. Twenty-one percent of these were order writing and transcribing errors, 38% were nurse or pharmacy dispensing errors, and 41% were nurse administration errors. Only three MAEs resulted in adverse drug events. Nurses were less likely to report MAEs that they felt were innocuous, especially late-arriving medications from the pharmacy. A retrospective review of 200 chemotherapy administrations found only one clear MAE, a miscalculated dose that should have been intercepted.

CONCLUSIONS

Significant reported MAE rates on our ward (0.04% of drug administrations and 0.03 MAEs/patient admission) appear to be relatively low due to application of current safety guidelines. An emphasis on studying MAEs at individual institutions is likely to result in meaningful process changes, improved efficiency of MAE reporting, and other benefits.

Multisite parent-centered risk assessment to reduce pediatric oral chemotherapy errors

PURPOSE

Observational studies describe high rates of errors in home oral chemotherapy use in children. In hospitals, proactive risk assessment methods help front-line health care workers develop error prevention strategies. Our objective was to engage parents of children with cancer in a multisite study using proactive risk assessment methods to identify how errors occur at home and propose risk reduction strategies.

METHODS

We recruited parents from three outpatient pediatric oncology clinics in the northeast and southeast United States to participate in failure mode and effects analyses (FMEA). An FMEA is a systematic team-based proactive risk assessment approach in understanding ways a process can fail and develop prevention strategies. Steps included diagram the process, brainstorm and prioritize failure modes (places where things go wrong), and propose risk reduction strategies. We focused on home oral chemotherapy administration after a change in dose because prior studies identified this area as high risk.

RESULTS

Parent teams consisted of four parents at two of the sites and 10 at the third. Parents developed a 13-step process map, with two to 19 failure modes per step. The highest priority failure modes included miscommunication when receiving instructions from the clinician (caused by conflicting instructions or parent lapses) and unsafe chemotherapy handling at home. Recommended risk assessment strategies included novel uses of technology to improve parent access to information, clinicians, and other parents while at home.

CONCLUSION

Parents of pediatric oncology patients readily participated in a proactive risk assessment method, identifying processes that pose a risk for medication errors involving home oral chemotherapy.

Development and implementation of an interdisciplinary oncology program in a community hospital

PURPOSE

The development and implementation of an interdisciplinary oncology program in a community hospital are described.

SUMMARY

Before the program was established, clinical pharmacists responsible for order entry and verification did not have a defined structure and resource to effectively communicate with medical oncologists and nurses on patient care issues and oncology drug information. The practice model did not meet practice needs, departmental safety, quality, or cost-saving goals. An interdisciplinary team was established to determine where current processes and procedures were needed to decrease errors and improve efficiency associated with chemotherapy services. Three stages of practice development were planned, and an interdisciplinary oncology program involving nursing and pharmacy team members and medical oncologists was established. Standardized order forms, various pharmacy collaborative agreements, protocols, improved oncology nursing and pharmacy processes, and established standards in order writing, dispensing, administration, and monitoring were developed. An oncology pharmacist specialist position was requested, and this pharmacist played an essential role in helping the hospital realize significant cost savings and improve the quality of care provided to patients receiving chemotherapy services. Data were collected for 96 chemotherapy orders before program implementation and for 75 orders after program implementation, and a 45% reduction in total error related to chemotherapy drugs was observed (p < 0.0625). The most common cause of errors was missing information, typically an omitted duration or frequency, dose, route, or premedication (63% of all errors documented).

CONCLUSION

The development and implementation of an interdisciplinary oncology program resulted in decreased medication-error rates, expanded pharmacy services, and cost savings.

US Cancer Center Implementation of ASCO/Oncology Nursing Society Chemotherapy Administration Safety Standards

PURPOSE

Because cancer chemotherapy is a high-risk intervention, ASCO and the Oncology Nursing Society (ONS) established in 2009 consensus- and evidence-based national standards for the safe administration of chemotherapy. We sought to assess the implementation status of the ASCO/ONS chemotherapy administration safety standards.

METHODS

A written survey of chemotherapy practices was sent to National Cancer Institute-designated cancer centers. Implementation status of each of 31 chemotherapy administration safety standards was self-reported.

RESULTS

Forty-four (80%) of 55 eligible centers responded. Although the majority of centers have fully implemented at least half of the standards, only four centers reported full implementation of all 31. Implementation varied by standard, with the poorest implementation of standards that addressed documentation of chemotherapy planning, agreed-on intervals for laboratory testing, and patient education and consent before initiation of oral or infusional chemotherapy.

CONCLUSION

Given wide variation in the implementation of ASCO/ONS chemotherapy administration safety standards at US cancer centers, there are significant opportunities for improvement.

Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs

Background

In spite of increasing efforts to enhance patient safety, medication errors in hospitalised patients are still relatively common, but with potentially severe consequences. This study aimed to assess antineoplastic medication errors in both affected patients and intercepted cases in terms of frequency, severity for patients, and costs.

Methods

A 1-year prospective study was conducted in order to identify the medication errors that occurred during chemotherapy treatment of cancer patients at a French university hospital. The severity and potential consequences of intercepted errors were independently assessed by two physicians. A cost analysis was performed using a simulation of potential hospital stays, with estimations based on the costs of diagnosis-related groups.

Results

Among the 6, 607 antineoplastic prescriptions, 341 (5.2%) contained at least one error, corresponding to a total of 449 medication errors. However, most errors (n = 436) were intercepted before medication was administered to the patients. Prescription errors represented 91% of errors, followed by pharmaceutical (8%) and administration errors (1%). According to an independent estimation, 13.4% of avoided errors would have resulted in temporary injury and 2.6% in permanent damage, while 2.6% would have compromised the vital prognosis of the patient, with four to eight deaths thus being avoided. Overall, 13 medication errors reached the patient without causing damage, although two patients required enhanced monitoring. If the intercepted errors had not been discovered, they would have resulted in 216 additional days of hospitalisation and cost an estimated annual total of 92, 907€, comprising 69, 248€ (74%) in hospital stays and 23, 658€ (26%) in additional drugs.

Conclusion

Our findings point to the very small number of chemotherapy errors that actually reach patients, although problems in the chemotherapy ordering process are frequent, with the potential for being dangerous and costly.

Experience with computerized chemotherapy order entry

PURPOSE

The elimination of errors related to chemotherapy administration remains an elusive goal. Computerized order entry has been shown to reduce errors. We assessed a chemotherapy computer order entry system for errors related to dosing and for the time required to prepare chemotherapy orders.

METHODS

A prospective study of all patients treated with chemotherapy over a 12-month period was performed. Chemotherapy order sets done via computerized order entry were reviewed for errors related to drug selection, dose calculations, decimal-point errors, and for exceeding a warning level set within the system. We also measured the time required to produce three order sets by hand versus by computer.

RESULTS

There were no errors in dose calculations, decimal points, or drug selection for 2,558 drug administrations in 235 patients treated with 26 different chemotherapy regimens. The dose warning level was exceeded in 152 (6%) of drug administrations, but never without user permission to override the warning. The average time saved per order set using computer order entry was 10 minutes (P < .05).

CONCLUSION

By using computer order entry with error-checking algorithms, it may be possible to eliminate a number of types of errors associated with chemotherapy administration without sacrificing efficiency.

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.

Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment

To enhance the quality and safety in cancer treatment, and in acknowledgement that medical errors occur, we have established 2 error management systems: one monitors chemotherapy errors, the other records all severe adverse events occurring in chemotherapy-treated cancer patients (SAECTx) in in- and outpatient treatment. These error systems have been implemented by our departmental "Clinical Service Center," a multidisciplinary team which controls all chemotherapy protocols and orders prior to the medication reaching the patient. We performed a prospective cohort study in consecutive cancer patients who received chemotherapies in our department between January 2005 and December 2006. Over this 2-year period, 2,337 patients were treated, with an equal distribution as in- and outpatients: 22,216 consecutive chemotherapy orders were analyzed, of which 83.5% were completely flawless, whereas we detected and corrected medical and administrative errors in 17.1%: in 3.8%, these errors involved the chemotherapy itself, in 4.5% the patient data and in 8.7% missing written informed consent forms. Chemotherapy errors were less frequent in outpatients than inpatients (3.3 vs. 4.5%, respectively). In outpatients, the rate of chemotherapy errors decreased from 4% in 2005 to 2.8% in 2006, but remained stable for inpatients (4.4% 2005 vs. 4.7% 2006). Among a total of 3,792 detected errors, only 3 reached the patient, resulting in an error rate in patients of 0.079%. Therefore, since we detected a substantial number of chemotherapy-related errors and intercepted 99.9%, we recommend our efficient surveillance system as an important safety check, thereby ensuring that chemotherapies are delivered error-free to cancer patients.

Medication errors among adults and children with cancer in the outpatient setting

PURPOSE

Outpatients with cancer receive complicated medication regimens in the clinic and home. Medication errors in this setting are not well described. We aimed to determine rates and types of medication errors and systems factors associated with error in outpatients with cancer.

METHODS

We retrospectively reviewed records from visits to three adult and one pediatric oncology clinic in the Southeast, Southwest, Northeast, and Northwest for medication errors using established methods. Two physicians independently judged whether an error occurred (kappa = 0.65), identified its severity (kappa = 0.76), and listed possible interventions.

RESULTS

Of 1,262 adult patient visits involving 10,995 medications, 7.1% (n = 90; 95% CI, 5.7% to 8.6%) were associated with a medication error. Of 117 pediatric visits involving 913 medications, 18.8% (n = 22; 95% CI, 12.5% to 26.9%) were associated with a medication error. Among all visits, 64 of the 112 errors had the potential to cause harm, and 15 errors resulted in injury. There was a range in the rates of chemotherapy errors (0.3 to 5.8 per 100 visits) and home medication errors (0 to 14.5 per 100 visits in children) at different sites. Errors most commonly occurred in administration (56%). Administration errors were often due to confusion over two sets of orders, one written at diagnosis and another adjusted dose on the day of administration. Physician reviewers selected improved communication most often to prevent error.

CONCLUSION

Medication error rates are high among adult and pediatric outpatients with cancer. Our findings suggest some practical targets for intervention, including improved communication about medication administration in the clinic and home.

Reducing medication prescribing errors in a teaching hospital

BACKGROUND

Medication errors occur frequently, result in significant morbidity and mortality, and are often preventable. A multifaceted intervention was conducted to reduce prescribing errors in handwritten medication orders written by house staff.

METHODS

A before-and-after design was used to evaluate the intervention--which included grand rounds, an interactive presentation for house staff, and reminders (a checklist, chart inserts, and requests for clarification)--and targeted 20 safe prescribing behaviors.

RESULTS

At baseline, prescribing errors were more common among surgical house staff than medical house staff (1.08 errors/order versus 0.76 errors/order, p < .001). Only 1% of orders contained an overt error, but 49% were incomplete, 27% contained dangerous dose and frequency abbreviations, and 17% were illegible. Postintervention, the mean number of prescribing errors per order decreased for surgical house staff from 1.08 (standard deviation [SD], 0.23) to 0.85 (SD, 0.11; p < .001), with a more marked effect for house staff who attended the didactic portion of the intervention. In addition, the mean number of the more significant errors per order decreased from 0.65 (SD, 0.19) to 0.45 (SD, 0.13; p < .001), and significant decreases occurred in the proportion of orders that were incomplete, were illegible, and contained an overt error. However, prescribing errors per order increased in orders written by medical house staff from 0.76 (SD, 0.14) to 0.98 (SD, 0.11; p < .001).

DISCUSSION

The intervention was associated with a modest improvement in the quality of medication orders written by surgical house staff. To reduce prescribing errors, multilevel interventions are needed, including training in safe prescribing for all physicians. Such training may need to be started in medical school and augmented and reinforced throughout residency.

Effect of computerisation on the quality and safety of chemotherapy prescription

BACKGROUND

Chemotherapy is prescribed according to protocols of several cycles. These protocols include not only therapeutic agents but also adjuvant solvents and inherent supportive care measures. Multiple errors can occur during the prescription, the transmission of documents and the drug delivery processes, and lead to potentially serious consequences.

OBJECTIVE

To assess the effect of a computerised physician order entry (CPOE) system on the number of errors in prescription recorded by the centralised chemotherapy unit of a pharmacy service in a university hospital.

PATIENTS AND METHODS

Existing chemotherapy protocols were standardised by a multidisciplinary team (composed of a doctor, a pharmacist and a nurse) and a CPOE system was developed from a File Maker Pro database. Chemotherapy protocols were progressively introduced into the CPOE system. The effect of the system on prescribing errors was measured over 15 months before and 21 months after starting computerised protocol prescription. Errors were classified as major (dosage and drug name) and minor (volume or type of infusion solution).

RESULTS

Before computerisation, 141 errors were recorded for 940 prescribed chemotherapy regimens (15%). After introduction of the CPOE system, 75 errors were recorded for 1505 prescribed chemotherapy regimens (5%). Of these errors, 69 (92%) were recorded in prescriptions that did not use a computerised protocol. A dramatic decrease in the number of errors was noticeable when 50% of the chemotherapy protocols were prescribed through the CPOE system.

CONCLUSION

Errors in chemotherapy prescription nearly disappeared after implementation of CPOE. The safety of chemotherapy prescription was markedly improved.

Prescribing oral chemotherapy

Standardised dosing can improve the safety of prescribing

Study of the effect of standardized chemotherapy order forms on prescribing errors and anti-emetic cost

OBJECTIVES

Many anti-neoplastic medication errors and excessive use of serotonin antagonist anti-emetic agents might be prevented by the use of a standardized chemotherapy order form (SCOF). Several studies showing a reduction in prescribing errors or control of inappropriate anti-emetic use through the use of SCOFs have been reported. No previously published study reported SCOFs were used to reduce both prescribing errors and anti-emetic cost. This study attempts to measure these outcomes in a haematology-oncology pharmacy service.

METHODS

The study consisted of a four-month control period, followed by a four-month test period following dissemination of the standardized order forms. In each period, prescriber errors and anti-emetic use were monitored. During the control period, using clinical studies from the primary literature and anti-emetic guidelines, 64 SCOFs representing the most commonly used chemotherapy regimens in the medical oncology and gynaecology oncology services were developed by the haematology-oncology pharmacy. Differences in prescribing error rate and anti-emetic cost were compared between each period and with the institution's historic prescribing error rate.

RESULTS

During the control period, 1078 orders for oral and parenteral granisetron and ondansetron with combined total acquisition cost of $76 454.64 and a mean cost of $70.92 were dispensed. During the test period, the pharmacy dispensed 1121 orders with an acquisition cost of $73 331.61 and a mean cost of $65.42. A savings of $3123.03 resulted from a reduction of the amount prescribed in the test period. The difference in mean cost per order between the two periods was significant (P <0.037). Fifty-three prescribing errors out of 3592 medication orders were detected in the control period, while 12 errors out of 3585 medication orders were detected during the test period. A significant difference(P <0.0001) was detected between the two periods. There was a significant difference (P <0.0001) between the control period and the institution's historic prescribing error rate and no difference between the test period and the institution's historic prescribing error rate.

CONCLUSION

SCOFs significantly reduced serotonin antagonist anti-emetic cost and prescribing error rate over a four-month period.

Medication safety in the ambulatory chemotherapy setting

BACKGROUND

Little is known concerning the safety of the outpatient chemotherapy process. In the current study, the authors sought to identify medication error and potential adverse drug event (ADE) rates in the outpatient chemotherapy setting.

METHODS

A prospective cohort study of two adult and one pediatric outpatient chemotherapy infusion units at one cancer institute was performed, involving the review of orders for patients receiving medication and/or chemotherapy and chart reviews. The adult infusion units used a computerized order entry writing system, whereas the pediatric infusion unit used handwritten orders. Data were collected between March and December 2000.

RESULTS

The authors reviewed 10,112 medication orders (8008 adult unit orders and 2104 pediatric unit orders) from 1606 patients (1380 adults and 226 pediatric patients). The medication error rate was 3% (306 of 10,112 orders). Of these errors, 82% occurring in adults (203 of 249 orders) had the potential for harm and were potential ADEs, compared with 60% of orders occurring in pediatric patients (34 of 57 orders). Among these, approximately one-third were potentially serious. Pharmacists and nurses intercepted 45% of potential ADEs before they reached the patient. Several changes were implemented in the adult and pediatric settings as a result of these findings.

CONCLUSIONS

In the current study, the authors found an ambulatory medication error rate of 3%, including 2% of orders with the potential to cause harm. Although these rates are relatively low, there is clearly the potential for serious patient harm. The current study identified strategies for prevention.

Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process

OBJECTIVE

To perform a risk analysis of the cancer chemotherapy process, by comparing five different organizations. To quantitatively demonstrate the usefulness of centralization and information technologies, to identify residual risks that may be the target of additional actions.

STUDY DESIGN

A reengineering of the process started in 1999 and was planned to be finished in 2006. The analysis was performed after the centralization and at the beginning of information technologies integration.

SETTING

Two thousand two hundred beds university hospital, with medical, surgical, haematological, gynaecological, geriatric, paediatric oncological departments. Twelve thousand cancer chemotherapies each year.

METHODS

According to the failure modes, effects and criticality analysis (FMECA) method, the failure modes were defined and their criticality indexes were calculated on the basis of the likelihood of occurrence, the potential severity for the patients, and the detection probability. Criticality indexes were compared and the acceptability of residual risks was evaluated.

RESULTS

The sum of criticality indexes of 27 identified failure modes was 3596 for the decentralized phase, 2682 for centralization, 2385 for electronic prescription, 2081 for electronic production control, and 1824 for bedside scanning (49% global reduction). The greatest improvements concerned the risk of errors in the production protocols (by a factor of 48), followed by readability problems during transmission (14) and product/dose errors during the production (8). Among the six criticality indexes remaining superior to 100 in the final process, two were judged to be acceptable, whereas further improvements were planned for the four others.

CONCLUSIONS

Centralization to the pharmacy was associated with a strong improvement but additional developments involving information technologies also contributed to a major risk reduction. A cost-effect analysis confirmed the pertinence of all developments, as the cost per gained criticality point remained stable all over the different phases.

Ten simple strategies to prevent chemotherapy errors

Safety experts currently recommend using technology to prevent medication errors. Computerized prescriber order entry, automated medication-dispensing machines, and bar coding are a few of the technologies being advocated to promote safety. Simple, easily implemented safety strategies to prevent chemotherapy errors should not be overlooked and include consistent use of a reliable method to verify patient identity, metric measurement, and workplace illumination and organization. Other strategies are elimination of abbreviations and acronyms, provision of up-to-date information at the point of care, and partnering with patients for safety. These strategies can be customized for use in a variety of practice settings. Oncology nurses are at the forefront of chemotherapy error-prevention initiatives and play a key role in implementing safety measures.

Chemotherapy error reduction: a multidisciplinary approach to create templated order sets

More than 48,000 newly diagnosed cancer patients can expect to have some adverse events related to their care each year. Historically, 20% of these adverse events have been medication related, and two thirds have been thought to be preventable. Since the majority of these errors occurred during the order writing process, the prioritized changes made at the joint pediatric program for Children's Hospital, Boston, and Dana-Farber Cancer Institute have been the initiation of templated orders and the development of a computerized order entry system. The goal of this initiative was to decrease errors related to chemotherapy administration by creating legible, complete, clearly defined order sets, and at the same time, to make order writing and reviewing more efficient. Chemotherapy templates were created using a consistent format and a rigorous multidisciplinary review process. Each order set includes the following: identification of the patient and cycle of chemotherapy to be given, criteria necessary to receive chemotherapy, chemotherapy orders with modifications if appropriate, and supportive care orders. Templated order sets have reduced the duplication of work efforts by significantly reducing the number of changes made during the order verification process; orders are more complete, and standardization has occurred.

A chemotherapy incident reporting and improvement system

BACKGROUND

The Vanderbilt University Medical Center (VUMC) has designed and deployed the Chemotherapy Incident Reporting and Improvement System (CIRIS), which is embedded into daily care processes. The system uses commercial information technologies, including handheld computers, to create a mobile Web-based chemotherapy incident reporting system for nurses and pharmacists. Two phases--(1) development and implementation of the CIRIS incident reporting safety registry and (2) development of the handheld-computer interface--were implemented. The final phase entails integration of the computerized order entry system into the front end of the CIRIS architecture. The voluntary incident reporting system data are stored over time for use by the multidisciplinary safety improvement team.

RESULTS

Staff buy-in has been demonstrated by increased reporting rates, the high number of provider-initiated improvements made to the reporting tool during the first year of implementation, and specific chemotherapy safety interventions conceived from analysis of the reported data.

CONCLUSION

The CIRIS model for pediatric chemotherapy safety improvement has been implemented in the inpatient setting but could easily be configured for a variety of other clinical applications in inpatient or outpatient settings. CIRIS has been effective, especially in the chemotherapy pharmacy, where incident reporting has increased dramatically.

Multidisciplinary systems approach to chemotherapy safety: rebuilding processes and holding the gains

PURPOSE

The problem of medication safety came to public attention largely through a chemotherapy error, and the high toxicity and low therapeutic index of anticancer medications make safety in their prescription and administration critical. We have undertaken a thorough revision of our systems for inpatient chemotherapy.

METHODS

We participated in a multi-institutional collaborative effort of the Institute for Healthcare Improvement, and used their rapid cycle change method. Particularly powerful systems change concepts were driving out fear, "trapping" errors and learning from them, focusing on outcome rather than on input, simplifying and standardizing, using constraints and "forcing functions," reducing handoffs, and paying attention to human factors.

RESULTS

Applying these concepts to our chemotherapy delivery system, we have achieved an 84% decrease in the number of chemotherapy errors that actually reach patients per 1,000 chemotherapy doses, and have sustained that improvement for 5 years.

CONCLUSION

Factors contributing to our success include the rapid cycle change method, strong support from hospital administration, grassroots participation, and a tradition of interdisciplinary cooperation. Computerized direct physician order entry and cooperative group participation have had mixed effects. Continued efforts at improvement have been key to holding our gains. Although specific problems and changes may not be relevant to other organizations, the concepts and methods we used are generally applicable.

Medication misadventure in cancer care

OBJECTIVES

To describe the nature and scope of the problem of medication errors in health care, with specific implications for error reduction and prevention.

DATA SOURCES

Articles and research studies.

CONCLUSIONS

Because of the complexity of chemotherapeutic regimens, requirements for supportive care drugs, and the physiologic vulnerability of patients due to their malignancies and intensive therapies, patients with cancer should be the focus of interdisciplinary medication error prevention programs.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a critical role in patient safety and the implementation of preventive and risk-reducing interventions to improve the drug delivery process.

Preventing medication errors in cancer chemotherapy referred to rural and remote hospitals

Patients from rural areas receiving simple chemotherapy regimens in regional or metropolitan centres are often sent back to their local hospital for treatment. As these centres commonly have health professionals with limited experience in the use of antineoplastic agents, it is particularly important to provide information that is accurate, thorough and has no potential for misinterpretation. The minimum information necessary has been identified in a previous study and includes patient details, diagnosis, chemotherapy protocol, dosages and method of confirmation, interval between cycles, supportive care and contact details for the prescriber. Staff at a number of small rural and remote hospitals were contacted to determine further useful information. Suggestions included: availability of premixed cytotoxics, methods of administration and possible adverse effects. A standardised computer format for providing oncological information was developed. Specific patient information is entered into the chosen protocol for each individual referred. This initiative has proven popular with participating hospitals and resulted in fewer inquiries and problems.

Variation in administration of cyclophosphamide and mesna in the treatment of childhood malignancies

The objective of this study was to describe the variation in preparation and administration of cyclophosphamide, mesna, and hydration for the treatment of childhood malignancies within clinical trial protocol documents. All cyclophosphamide-containing cooperative group (Pediatric Oncology Group) protocols that were open at Dana-Farber Cancer Institute in April 1998 were evaluated. Among the 14 active protocols, there were 23 unique cyclophosphamide regimens. Marked variation existed in infusion rate, fluid type, and volume used for admixing cyclophosphamide and mesna, as defined in the "Treatment" section of the protocols that we evaluated. Further variation was found in the type, amount, and rate of infusion of prehydration and posthydration fluid. Internal inconsistency existed within the protocols pertaining to the administration methods described in the "Agent Information," "Treatment," and "Consent" sections of the written documents. Clinical trial protocol documents serve as reference material for health care providers who prescribe, dispense, and administer protocol chemotherapy. Misinterpretation of protocol documents and clinician orders are contributing factors in serious and deadly medication errors. Internal inconsistency within protocol documents and variation in drug administration across protocols is a potential source of error. We recommend improved accuracy, clarity, and internal consistency of protocol documents to improve patient safety and compliance with protocol specifications. In addition, the use of standard concentrations, volumes, and methods of administration of chemotherapeutic agents and accompanying fluids is recommended.

Accidental iatrogenic intoxications by cytotoxic drugs: error analysis and practical preventive strategies

OBJECTIVES

Drug errors are quite common. Many of them become harmful only if they remain undetected, ultimately resulting in injury to the patient. Errors with cytotoxic drugs are especially dangerous because of the highly toxic potential of the drugs involved. For medico-legal reasons, only 1 case of accidental iatrogenic intoxication by cytotoxic drugs tends to be investigated at a time, because the focus is placed on individual responsibility rather than on system errors. The aim of our study was to investigate whether accidental iatrogenic intoxications by cytotoxic drugs are faults of either the individual or the system. The statistical analysis of distribution and quality of such errors, and the in-depth analysis of contributing factors delivered a rational basis for the development of practical preventive strategies.

METHODS

A total of 134 cases of accidental iatrogenic intoxication by a cytotoxic drug (from literature reports since 1966 identified by an electronic literature survey, as well as our own unpublished cases) underwent a systematic error analysis based on a 2-dimensional model of error generation. Incidents were classified by error characteristics and point in time of occurrence, and their distribution was statistically evaluated. The theories of error research, informatics, sensory physiology, cognitive psychology, occupational medicine and management have helped to classify and depict potential sources of error as well as reveal clues for error prevention.

RESULTS

Monocausal errors were the exception. In the majority of cases, a confluence of unfavourable circumstances either brought about the error, or prevented its timely interception. Most cases with a fatal outcome involved erroneous drug administration. Object-inherent factors were the predominant causes. A lack of expert as well as general knowledge was a contributing element. In error detection and prevention of error sequelae, supervision and back-checking are essential. Improvement of both the individual training and work environment, enhanced object identification by manufacturers and hospitals, increased redundancy, proper usage of technical aids, and restructuring of systems are the hallmarks for error prevention.

CONCLUSIONS

Errors follow general patterns even in oncology. Complex interdependencies of contributing factors are the rule. Thus, system changes of the working environment are most promising with regard to error prevention. Effective error control involves adapting a set of basic principles to the specific work environment. The work environment should allow for rectification of errors without penalty. Regular and ongoing intra-organisational error analysis needs to be an integral part of any error prevention strategy. However, it seems impossible to totally eliminate errors. Instead, if the environment guarantees timely error interception, most sequelae are avoided, and errors transform into a system-wide learning tool.