Strategies for Preventing Chemotherapy Errors

 Laurl at ONS 

Welcome to today's hot topic chat on strategies to prevent medication errors. Today's expert is Mikaela Olsen. Please welcome Mikaela!

 bubbles 

Welcome

 molsen 

Hi, where are you all from?

 bubbles 

Detroit

 SUSAN 

NC

 bboseski 

New York

 sal 

sal=Indiana

 rose647 

Houston

 molsen 

Great, I am in Baltimore, MD at Johns Hopkins Hospital.

 molsen 

Does anyone have a specific question before we start?

 bubbles 

At work today we were discussing Rituxan adm. in an IPD setting.

 molsen 

What is an IPD setting?

 bubbles 

In patient

 molsen 

Ok, where you discussing potential errors with Rituxan?

 bubbles 

Safety with infusion- we usually schedule one-on-one staffing for the first infusion.

 bubbles 

But, if a patient has not had Rituxan in over six months, do we need to go back to one-on-one staff?

 molsen 

That is great if you have the staffing to do that. We usually have 2-3 pts total and the nurse who infuses a first dose of Rituxan usually has another nurse watch her other patients during the titration period.

 sal 

Related, has anyone been doing the 90 minute infusion for Rituxan? Staffing for this?

 bboseski 

Same thing where I practice.

 molsen 

It really depends upon prior history of reactions, tumor burden and how sick the patient is. I don't think all inpt facilities have the staffing to do one on one.

 hazel85 

We have 32 chairs and 6-8 nurses in the infusion room so that's not practical for us. But things like Rituxan Taxol, etc where a reaction is possible - those pts go in certain chairs most visible to us.

 bubbles 

Right, our OPD doesn't one-on-one.

 askren 

We do a one to one when Rituxan the nurse must remain in the room for the entire infusion.

 bubbles 

opd= outpatient

 sal 

Do you all see many reactions to warrant 1:1 staffing?

 molsen 

We do not do 90 minute Rituxan infusions on the first dose however, if they do well then subsequent doses are given faster.

 hazel85 

Yes we do 90 minute Rituxans and Carbo desensitization, which takes ALL day 10+ hours, so we just can't take one nurse out of the mix for a whole day. We each average 6-10 pts per day.

 bubbles 

Ipd ( inpt dept) different, behind closed doors.

 molsen 

I agree patient visibility is important. Also, having emergency equipment available, knowing how to respond quickly to a reaction.

 askren 

We don't have many reactions, but as an in-patient we are limited on how often we could get back to the room and the docs wanted VS every 15 minutes times 6 and thirty minutes till the infusion complete and it was the only way we could guarantee that was done

 bubbles 

We do occasionally see reactions- 2 in 5 years.

 bboseski 

Reactions yes; that require 1:1, not really.

 askren 

All of our emergency standing order drugs are taken in when we go in.

 bubbles 

Us too

 bboseski 

Same here

 sal 

Do you all use the double or triple check system like recommended in the ONS chemo course to prevent errors?

 molsen 

It is a good practice to have your emergency drugs and equipment readily available.

 bubbles 

Double

 askren 

We do a double check on transcription and drug check off at hang time.

 bboseski 

Two RN's Chemo certified RN's check

 hazel85 

We have a cart nearby and a bag of STAT drugs, some of us are ACLS certified. We probably have maybe 2 reactions a month. We started running the Benadryl first on those pts to give it time to saturate the receptors.

 molsen 

Independent double checks are key! With many new RNs we encourage them to feel
empowered to do an independent check in a calm environment and not feel rushed by other staff members.

 askren 

How are you administering vincristine?

 sal 

We have a chemo task force that reviews all chemo errors. Thankfully we are underworked in this effort. Was thinking that perhaps our double and triple checks were preventing a lot of potential errors.

 bubbles 

Us too- but is all this necessary for a patient who hasn't received the drug in 6 mos? A year?

 bboseski 

I have a question for the group is there one particular agent that they find medication errors occurring frequently. One common practice I find is that with multiple agent regimens RN's usually check all the agents together. Rather then one at a time.

 sal 

We are now giving Vincristine in the mini bag as recommended by ISMP.

 hazel85 

Our drugs are checked @ order, double checked by nurse and pharm tech in pharmacy, when distributed to pt (by pt name and stated DOB) and again by stated name and DOB when drug is started by 2 nurses.

 askren 

Our vincristine is mini bag as well

 bubbles 

Us too

 sal 

We use the same system as hazel85 and it seems to work well.

 bubbles 

With a large warning label

 askren 

The biggest errors we have had is chemo being given at the wrong time, due to computer placing all chemo meds in for am administration regardless of the time it was given the day before.

 hazel85 

VCR ( vincristine)  is IVP through flowing IV line - we elected to give all vesicants this way so they could be observed. Too risky to run a vesicant if it infiltrates.

 molsen 

Care must be taken when checking off multiple drugs in a chemo regimen. Each drug should be independently checked and dose recalculated, labs verified etc. It is easier to make an error when multiple drugs are being checked off at the same time. The IT drugs should be stored and checked separately related to the vincristine issue.

 molsen 

At my institution we are getting ready to go up on POE  ( physician order entry) and this timing issue was a main concern for us. We are going to have all chemo go into a holding pattern and the nurse is going to time the chemo.

 hazel85 

Sounds like there’s a big difference in practice between inpt and outpt.

 sal 

We use a chemo calendar (paper) to track our doses and even though an extra step, seems to keep the multi-dose regimens on time and in order.

 bubbles 

Hazel, you said a mouthful!

 bubbles 

IPD and OPD are like two different worlds.

 molsen 

In physician order entry...this is going to be a big change for us but we feel that the nurse in the outpt area or the inpt nurse has a better handle on the chemo due times to prevent mis-timing. This will be double checked by two RNs.

 askren 

What we did with the timing issue was keeping a paper copy of the Chemo administration record that is good for 7 days so we could look at the time on it and not the computer

 hazel85 

Outpt is easier to manage drug timing and order, but even though everything is on a pump, those things are still not entirely accurate.

 bubbles 

True

 askren 

We administer outpatient chemo in an inpatient unit and this can cause challenges as procedures and computer/paper work is different.

 molsen 

We also use a chemotherapy checklist- which is still on paper. On the back of this safety checklist nurses sign off the drugs and times. Like some of you, we use this as a double check.

 hazel85 

Us too

 askren 

We do as well

 bubbles 

We use a dictation method that is immediately to all staff via computer.

 molsen 

Yes, when patients come into the inpt area and need to continue their outpt regimens this can be challenging. It is a lot of work to rework the plan and rewrite the orders safely.

 molsen 

Can you describe your dictation method a little more for folks?

 hazel85 

How did you do that? With our EMR we're lucky to get last dictation in 2 weeks!

 lmocaby 

Do you use printed order sets or handwritten orders?

 bubbles 

We dictate premeds, labs, oncologist, regimen, day, etc... on a computer template that is immediately available- takes RN approximately 5-10 minutes

 askren 

Handwritten orders all except for RCHOP

 bboseski 

Electronic chemo order sets

 bubbles 

orders on computer- no handwritten (boo to handwritten).

 hazel85 

Bubbles, what EMR do you use; is this inpt or outpt?

 streeterb 

Are you using a commercial template or something you developed at your facility?

 bubbles 

IPD, OPD throughout the whole system- all linked.

 bubbles 

We developed our own template

 bboseski 

 We use commercial that has been modified to fit the different service areas and their Tx regimens.

 bubbles 

Are now developing standardized order sets available to all staff throughout system (approximately 7 hospitals).

 streeterb 

Would love to see these - we use handwritten set and they are difficult...

 askren 

We have had some push back on standardizing order sets.

 bubbles 

I bet- our docs still screw up computer orders! (sorry Molson)

 molsen 

Preprinted orders help improve safety because they can be reviewed and approved through a multidisciplinary team, include premeds, emergency meds, monitoring guidelines etc. We have over 200 preprinted orders here at JHH and are developing them in physician order entry as we speak. NCCN also has developed order templates for some regimens.

 hazel85 

We use and EMR and it's still difficult. Would love to see the custom templates. Our docs would probably have a stroke!

 bubbles 

We had/have a lot of resistance to standard orders.

 askren 

Moslen is there a way that you could share a couple of these as examples

 streeterb 

Anyone else from a teaching facility? Many of our concerns stem around new Fellows writing orders.

 molsen 

Yes, our major problems have been docs crossing out things on preprinted orders or modifying doses. This is not allowed per our policy. Our standard orders are considered "standard" for the reasons stated above so they cannot be changed. If they are changed it is individual chemotherapy which means not according to a set standard at our institution.

 bubbles 

I love July and new fellows! (not really)

 molsen 

I can post some examples of preprinted orders on to the transcript from today's chat on the hot topics webpage by tomorrow.

 askren 

Great thanks

 hazel85 

That would be great

 bubbles 

That would be great-thank you

 bboseski 

At my facility only attendings can write chemo orders.

 molsen 

Yes, I even cancelled my July 4th holiday b/c I was scared what might happen to our pts. Ha!

 molsen 

All went well and everyone was safe! Until next year...

 streeterb 

Same for us - attending must cosign but "teaching" new Fellows requires sharp nurses.

 bubbles 

Us too- but the attendings don't read the fellows order before they sign them! (LOL Molson)

 hazel85 

July is the month when you get to train residents and fellows and indoctrinate them to do things your way -HA

 sal 

We do not allow anyone but staff to write chemo orders for oncology and we do not accept any written orders. However, the derm/GI areas can bend the rules as it is technically not for cancer management.

 askren 

Are any of you inpatient and have NP's rounding and completing/clarifying chemo orders

 streeterb 

I do

 bubbles 

yes

 molsen 

At our institution the attending is the final sign off. Two attendings must sign if individual chemo is written and there is not a reputable reference.

 bubbles 

I love that molson!

 bubbles 

Can you talk to our director!?

 molsen 

We have one inpt NP on our heme onc service who was a nurse on this unit for >10 yrs so she is very helpful to the residents and fellows.

 askren 

Are there any issues with the NP wrtting/clarifying chemo orders as an Inpt?

 streeterb 

Our NP developed an audit form so we can have a daily review of inpatients receiving chemo - has been very helpful with communication between Pharm, docs and nsg.

 molsen 

The NP can never do it independently; it must be signed by an attending MD.

 bubbles 

We have 3 NPs- do a great job- audit form, streeterb? Would love to see it.

 hazel85 

We are outpt and have PAs who see pts in F/U. Their orders are cosigned after the fact but I don't think the MDs really look at them. As always, it is the nurse's responsibility to know if the doses are appropriate for the regimen and to calculate doses/ BSA

 molsen 

Your audit form sounds interesting, is it done in real time as the patients are receiving chemo?

 sal 

Our NP/PharmD can only clarify. Writing a new order must be from the attending--can be faxed to the unit.

 streeterb 

Daily review during rounds

 bboseski 

Anyone willing to share a chemo error and what they learned from it?

 bubbles 

Our NP/PA can write orders , but staff must sign.

 streeterb 

And I'd be glad to share if someone will let me know how. This is my first chat :)

 bubbles 

Wrong weight last week

 Laurl at ONS 

Streeterb, you can send anything like your audit form to me at lmatey@ons.org and I'll make sure it gets into the chat transcript - it will be posted tomorrow!

 bboseski 

Bubbles how did you discover that?

 bubbles 

Fellow said- "patient looked to be 200 lbs" was actually 160 lbs.

 askren 

We catch several errors on BSA but those are all corrected prior to mixing and administration.

 bboseski 

Wow

 hazel85 

One of our nurses once hung chemo on wrong pt... It was busy and she was distributing chemo to several pts, put wrong bag in pt's basket and error was compounded when another nurse hung and started it. That's why we now have 2 nurses ID pt and sign off.

 molsen 

An outpt came in for carboplatin; MD used an old creatinine of .9 on the orders. The pt came to the lab area at 0800, had labs drawn. Came to the clinic at 10am and the nurse did not independently check the creatinine and instead used the MD stated creatinine. The actual creatinine from that day was 7.8. The pt got carboplatin and ended up in the hosp for 3 weeks. Nurses must always check their own source data!

 bubbles 

Re: wrong weight pt: This was caught on admission- but really? Not weighing patients before writing orders?

 sal 

Had a patient who received the wrong dose of Carbo as the nurse
did not recalculate the AUC. This then became a competency for last year.

 hazel85 

I once gave 700+ Rituxan in 45 minutes due to what proved to be a malfunctioning pump. Pt was OK because she didn't have a large tumor burden, but after 20+ years giving PO chemo, I almost vomited!

 bubbles 

Carbo can be tough

 molsen 

It is a good practice to get your own height and weight (in CM/KG) and recalculate your doses.

 streeterb 

We recently experienced lack of supportive measures for patient receiving high dose ARA-C. Nurses are drilled to double-check everything as our Fellows frequently "copy" the orders from the previous cycle so the initial order errors continue. This is one reason I'd love to have the templates!

 bboseski 

We recently went to flat dosing for Carbo

 bubbles 

Flat dosing?

 askren 

We recalculate everything (we should sometimes not all nurses do)

 bubbles 

Us too, but it is soooo time consuming to get the orders fixed.

 molsen 

Carboplatin is a challenging drug and nurses must be familiar with the formulas and how to verify dosing. The ONS chemotherapy and biotherapy guidelines have good instructions for this.

 streeterb 

We have a BSA calculator built into our electronic system - working on getting the carbo formula in as well.

 molsen 

streeterb- are you talking about copy forward in a computer system or on paper?

 askren 

Yes as an Inpt we have had to wait 4 hours to get clarified orders on a patient that could be discharged after the infusion...

 hazel85 

Our EMR has the formula and recalculates the AUC every dose

 bboseski 

First dose is calculated on AUC and the dose remains the same for the entire cycle.

 bboseski 

Of course the treating RN needs to check the labs prior to treatment

 molsen 

Do any of you use a chemotherapy checklist to do your safety checks?

 askren 

We have a Clinical Pharmacology application that has several calculators and the ANC and BSA are both on there

 bubbles 

no

 streeterb 

Same -Clinical calculator

 askren 

We have a self made checklist, but not everyone uses it.

 bboseski 

Can you share what is listed on the safety checklist?

 molsen 

A checklist can be helpful because it encourages everyone to do the same safety checks. This prevents the good guy- bad guy phenomena. If all nurses stick to the same safety rules then MDs get used to what is expected. After 9 years of using our checklist MDs definitely know the rules. They still sometimes try to get around them but they know!

 sal 

We use a checklist for our "off the floor chemo" to assure that all areas are covered including education the nurse caring for the patient about potential issues with the drug after infusion since the patient is not on the oncology unit.

 molsen 

I can post a copy of the checklist on the transcript with the orders. It is also published in a book called "measuring safety". I can post that reference as well.

 bubbles 

Us too sal

 bubbles 

Thanks molson

 molsen 

Yes, our checklist is hospital wide for ALL doses of chemo given. It is helpful for non oncology nurses to do the same safety checks when giving these drugs.

 askren 

You have non chemo nurses giving these drugs?

 streeterb 

Do you allow non-credentialed staff to administer?

 molsen 

This is a challenge in many hospitals across the country...

 bboseski 

Most of our chemo errors are related to Baxter bottles for continuous 5 FU infusions. Does anyone else use these bottles in their practice?

 hazel85 

Re; Non chemo nurses: Scary, given the complexity of drugs and regimen these days.

 sal 

No, our nurses with ONS chemo provider cards administer drugs thru-out the hospital. What a staffing nightmare.

 bubbles 

We stopped- Baxter bottles are problematical

 bubbles 

Us too sal- it is a staffing nightmare!

 streeterb 

Sal - Same for us - and it is a staffing fiasco at times.

 askren 

We only allow chemo nurses to administer. Currently there are 22 in our two hospital system all on one campus so we float them to the other hospital to administer.

 bboseski 

Re: Baxter bottles: I am realizing that now…

 hazel85 

Our continuous 5FU goes on a CADD pump.

 molsen 

Our hospital has non chemo nurses in the rest of the hospital go through a self learning module on chemo safety as well as safe handling. We don't give a lot of chemo outside of the oncology center and if it is one of our pts on a complicated regimen we will transfer them to us or go to them to give chemo. However, nurses in the hospital give monoclonals and chemo for a variety of reasons so they can be taught as described above.

 bubbles 

Do they pay you for drive time?

 molsen 

JHH is 1200 beds so I think this is why we do it this way.

 askren 

Yes but we are only 7 minutes apart and the mileage is small

 hazel85 

How's that for reimbursement? Our outpt center can't get reimbursed for giving chemo to an inpt, even though we are right in the hospital.

 bubbles 

we do too Molson- like for transplant

 streeterb 

We've had discussions - some of our rheumatology patients receive agents but they admit them to our unit.

 hazel85 

Our local rheumatologists are giving their own stuff now - yippee

 askren 

Any renal, rheumatology, or anyone else who needs a "chemo" must come to our unit.

 sal 

Unfortunately our nephritis patients are admitted to the renal unit and the Cytoxan is administered there. Also an oncology pt may be on a vent and in the ICU so we go there as well.

 lmocaby 

That is the way our hospital does administration of chemo agents.

 bubbles 

We get pulled throughout the hospital for rheumatoid patients.

 streeterb 

Same for us - we also see a lot of TTP here and they are frequently ICU patients.

 bboseski 

Oral Chemo can be given by non-certified RN's.

 askren 

Oncology nurse will travel

 molsen 

Regarding reporting of these errors? Are you all comfortable reporting errors, do your work environment and leadership encourage reporting?

 askren 

I am working on education for those oral meds.

 sal 

Speaking of sister hospitals, I have to run over to our other facility. It has been great and I look forward to seeing the full transcript soon. Have a great day. sal

 bubbles 

our problem is when the non oncology MD wants to have his resident write the order and wonders why this is wrong.

 lmocaby 

If patients receiving chemo are on a critical care unit a chemo nurse is floated to the unit to monitor the chemo.

 streeterb 

Definitely - we have a Patient Safety Net system that we are encouraged to use.

 askren 

We take errors as a learning opportunity

 bboseski 

Absolutely

 hazel85 

Yes, no fallout unless it would be repeated. Mgmt is very supportive and the docs are usually not as hard on us as we are on ourselves

 bubbles 

us too

 Laurl at ONS 

Just FYI, ONS does now have a trainer course re: giving chemo in non-chemo settings. You might find that of help in some of your settings. Look in CNE Central- live programs.

 bboseski 

Same here

 molsen 

Wonderful, it sounds like many of you have environments that support a non punitive environment.

 askren 

Most of the docs are nice about it.

 molsen 

Do you all regulate prescription writing for oral chemotherapy drugs with the same rules? For example does an attending have to sign all oral chemo scripts/ targeted drug scripts?

 streeterb 

Ours do.

 hazel85 

Nope, just electronic signatures

 bboseski 

Same here electronic orders and signatures

 askren 

As an Inpt any IV orders must be on the Chemotherapy order form however PO can be on a regular order form.

 bubbles 

Us too

 molsen 

Culture of safety should be "just", staff should not be punished however, there should be no tolerance for deliberate violations or misconduct. Do you all find that your environment focuses on the systems issue that caused the error rather than the person?

 hazel85 

Absolutely

 bboseski 

Yes

 bubbles 

Us too

 askren 

Yes

 lmocaby 

Yes. We use the just culture theory when investigating errors.

 molsen 

A really nice article that I found helpful! "Errors in Medicine" Lucian L. Leaped. 2009. I can post this reference.

 bubbles 

What it that? “Just”?

 streeterb 

One of the things that grew out of our PSN system was a safety task force that looks at safety concerns and tries to address them proactively.

 molsen 

This article talks about the just culture and other aspects of culture that are recommended.

 hazel85 

How does staffing and outpt acuity fit into that?

 streeterb 

Now there's a loaded ?  !!!

 molsen 

One of the major causes of errors is stress as you all know. Increased acuity and staffing issues potentiate this and do increase the risk of error.

 Laurl at ONS 

Great discussion, folks - while Mikaela is answering the loaded question (!) Just a reminder that we have about 4-5 more minutes- if you have any other specific questions....

 hazel85 

As I said before one of our major errors happened when we were crazy busy and just running. We usually do not allow ourselves to be rushed for any reason. But I worry about all these things we are responsible for and the docs just think we are the safety net. We are all pretty much living on the edge every day.

 molsen 

We struggle with unbelievable outpt numbers also...I think team work is paramount. Respecting each other also and ensuring that our leadership hears our concerns.

 bubbles 

A good sense of humor helps

 hazel85 

And therein lies the rub!!

 molsen 

Are there any other questions about medication safety? I can post some helpful documents to share as examples.

 Laurl at ONS 

Thanks so much for your great discussion - we appreciate your input. Mikaela's transcript will be posted sometime tomorrow on the ONS hot topic web pages.

 bubbles 

Thanks!

 Laurl at ONS 

The next chat is tomorrow night at 7:30 pm ET.

 molsen 

All of you had really great comments, thanks so much for sharing!

 Laurl at ONS 

Please tell your coworkers to come and join the discussion! Many thanks Mikaela for your insights today.

 hazel85 

Thank you everyone. Can't wait to read the transcript and digest all this good info. Have a wonderful day. Only 3 more days to go!

 Laurl at ONS 

Have a great day!

 molsen 

Hope to see you all tomorrow at 7:30pm! Thanks!