18 GREEN HILL HEALTHCARE COMMUNICATIONS January/February 2009

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Safe HandlingThe Right Drug, Right Dose, Right Patient…

BY ANDREW SCOTT, BSC, RN, OCN

INTRINSIQ, LLC, WALTHAM, MASSACHUSETTS

Healthcare providers have allheard the phrase “the rightdrug, right dose, right patient”

more than once during training on safedrug administration. In the real world, itquickly becomes apparent that there is alot more that needs to be considered.

Nowhere is this challenge more acutethan in the world of oncology. Mostchemotherapies consist of multipledrugs, and every drug administrationinvolves a uniquely calculated doseusing complex combinations of formu-las. The majority of drug doses require adrug volume to be calculated and specif-ic reconstitution guidelines to be fol-lowed. Timing and frequency of admin-istration is an important part ofmaintaining patient safety. All of thisoccurs before the drugs get anywherenear the patient.

Added to the mix are complexrequirements of drug administration. Arecent study that focused on medicationerrors specifically in pediatric oncologyfound that 85% of errors reached thepatient. Of those errors, 48% originatedin the administration phase of medica-tion delivery compared with 30% dur-ing the prescribing phase. The mostcommon error type was improperdose/quantity (22.9%) followed byerrors of omission, wrong routes, oradministration techniques.1

Oncology professionals have to dealwith many more aspects of drug admin-istration accuracy and safety. Manyindividuals with a range of professionalskills are involved in the chemotherapyadministration process. Outside thehospital environment, it is still com-monplace for the chemotherapy nurseto assume the role of pharmacist orpharmacy technician and be responsiblefor reconstituting drug doses as well asadministering them.

In the study by Rinke and colleagues,1

performance and knowledge deficitsaccounted for nearly 49% of errors.Also, the rate of prescribing errors was

almost double in the outpatient settingcompared with inpatient units. InFebruary 2008, USA Today reported anincident involving a 2-year-old girl inwhich the pharmacy technician mixedher chemotherapy drug with a salinesolution 26 times above normal. Thiserror went unnoticed by both the on-duty pharmacist who checked the for-mulated dose (despite the fact the bagwas clearly labeled with the fluid con-centration) and the nurse administeringthe drug. Prescribing errors have alsooccurred in which the bag was labeledcorrectly but the drug was preparedincorrectly and the nurse had no way ofknowing that. In both such cases, theerrors only become apparent after theevent and manifest in problems experi-enced by the patient, which in the caseof the 2-year-old girl was death.

Instituting safeguards and efficiencies

What has technology done to helpimprove our lives as oncology profes-sionals? We are now using software ormedical devices throughout many phas-es of the chemotherapy delivery process,from prescribing and regimen manage-ment to drug dosing and administration.

Electronic medical records (EMRs)are designed to enhance patient safetyby automating every aspect of a patient’scare, from drug administration to recordkeeping, but they are not widely accept-ed in the specialty of oncology. Manyoncology modules have been intro-duced in the past decade, often withoutsuccess. Even the most sophisticatedgeneral practitioner order entry mod-ules fail to provide oncology practition-ers with the robust tools and flexibilitynecessary to calculate complex doses,prescribe multiple drug combinations ofchemotherapy regimen, or manage thescheduling of the treatment plan. Thishas resulted in frustration for oncolo-gists and their teams, who find theyneed to continue to do a large part oftheir work on paper.

Oncology practices are often reluc-tant to use hospital-mandated oncol-ogy EMR modules, preferring insteadoncology-specific computerized phy-sician order entry (CPOE) solutionsfor the management of core chemo-therapy delivery. These systems auto-mate the complete treatment cyclefor each individual patient, providingdetailed treatment regimens by disease,managing drug calculations and sched-uling, monitoring dose levels and con-traindications, as well as offering com-pounding tools for pharmacists.

These solutions have now pro-gressed to offer documentationoptions for both the chemotherapynurse and the physician, creating acomprehensive oncology patientrecord that can also deal with thecomplex billing process that followsevery chemotherapy encounter. Thisneed has been heightened by the dra-matic reimbursement changes affect-ing every aspect of the oncologypractice. In addition to managing theclinical aspects of chemotherapy,these specialist solutions are nowleveraging the data captured withinthe course of treatment to providesophisticated charge capture toolsthat aim to minimize “lost” billings.

Aside from removing the error-prone tasks of dose calculation,oncology CPOE tools eliminate theother main source of error, transcrip-tion, since all information emanatesfrom a single source, the chemother-apy treatment plan. The chemother-apy order, pharmacy worksheets, druglabels, and nurse charting prescrip-tions are immediately available. Theonly human interventions in thisprocess are the clinical reviews of theorder and the detailed error checkingthat these systems provide, by thenurses, physicians, and pharmacists.

CPOE integrates with oncologypractice workflows

Once the electronic chemotherapyorder is checked and the drugs areready for compounding, most institu-tions still rely on a person to formulatethe required doses. Despite the safe-guards provided by CPOE systems,accuracy depends on the diligence ofthe individual and the strictness of the

verification processes at the insti-tution. Some of the most common“best practices” include a minimumof two people checking the order,checking the drugs during dispens-ing and before administration, andconfirming the patient informa-tion.

Sophisticated automated com-pounding technologies exist, butmany of these are prohibitive incost and have limited practicality

in the smaller oncology setting. Ac-cording to the American Society ofClinical Oncology, more than 80% ofcancer patients receive chemotherapyin private practices.2

The final step of drug administrationonce again requires human interven-tion. CPOE has helped by providingdetailed, legible, and accurate orders aswell as charting tools to allow real-timecomprehensive note taking. Althoughdocumentation tasks may includeprompts to verify drugs before adminis-tration, similar potential risks areencountered, since accuracy is still pre-dominantly reliant on diligent practi-tioners and strictly applied processes.

Bar coding of patients and medica-tions in an effort to ensure that thecorrect medication is given to the cor-rect patient has been implemented inthe Veterans Affairs (VA) system, withmixed reviews. The VA hospital net-work has a proprietary system, BarCode Medication Administration,which they say has led to a 74% reduc-tion in the risk of administering thewrong medication and a greater reduc-tion in the risk of medications beinggiven to the wrong patient. However,providers have found the process inef-ficient and unreliable. Although sup-ported by the US Food and DrugAdministration, such solutions arelikely to have little impact on thesmaller private practices, where theeconomics of such a solution could notjustify their investment. A studyspecifically of the VA system conclud-ed that the bar coding system may itselfcreate new sources of adverse drugevents. One of the key issues cited wasthe confusion caused by the automatedremoval of medications from theinventory cabinets.3

The introduction of oncology-spe-cific chemotherapy management sys-tems has done much to eliminatesources of potential error. Humanaction is often a key element, andhuman error is the precipitant event inmany drug-related errors. Often, how-ever, these are just symptoms of widersystemic failures, which, if addressed,may have prevented the error fromoccurring.

References1. Rinke ML, Shore AD, Morlock L, et al.

Characteristics of pediatric chemotherapy med-

ication errors in a national error reporting data-

base. Cancer. 2007;110:186-195.

2. Huff C. Chemo and Medicare. Could a new

payment plan force more cancer patients to

your doorsteps? Hosp Health Netw. 2004;78:62-

64, 66,1.

3. Patterson E, Cook RI, Render ML. Improving

patient safety by identifying side effects from

introducing bar coding in medication adminis-

tration. J Am Med Inform Assoc. 2002;9:540-

553.

The majority of drug doses require adrug volume to be calculated and specificreconstitution guidelines to be followed.

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