Strategies for Preventing Chemotherapy Errors

 olsenmi 

Hi everyone, My name is Mikaela and I will be leading our chat. Where are you all from?

 amazing 

Florida

 Laurl at ONS 

Tonight we are talking about Medication Errors and how to prevent! Please ask your questions!

 marvin1379 

New York

 steph199 

Florida

 shecatar 

I’m in middle east now (Riyadh)

 Laurl at ONS 

You definitely get the prize for the person who is up the latest to be at this chat!

 Laurl at ONS 

Welcome dfritz- please ask your questions!

 olsenmi 

Do any of you have specific questions regarding medication errors of any type?

 Laurl at ONS 

Welcome - please ask your questions!

 marvin1379 

I work in a busy ambulatory chemo administration unit (about 80 patients daily) and we double check our chemo before administering it. The institution has recently changed the policy to check each chemo prior to administration, not all of them in the regimen. What are the practices of your institutions in regard to double checking chemo, as well as how many chemos at one time.

 mlyne 

Is there evidence that scanning systems (of id bands) reduces chemo errors?

 Laurl at ONS 

Great questions - Mikaela will answer in order!

 dfritz 

With electronic medical records and electronic order entry, we seem to be hampered by the thought processes of the IT world/personnel that developed the system. User input can vary into a system. What suggestions do you have for electronic order entry?

 shecatar 

for right person here we don’t rely on the name only but also the patient number written on id band

 janet558 

hi everyone, I'm Janet

 olsenmi 

At Johns Hopkins we do our initial checks of the entire regimen to ensure that there are no major errors in dosing or lab values that would preclude administration of the regimen. Each individual drug is also double checked prior to administration and then at the bedside with the patient.

 marvin1379 

We always use 2 patient identifiers

 mlyne 

We have given chemo for years and years by using two identifiers for patient and have done it safely. The scanning system does not seem to be the "last word in safety" because you can still give the wrong patient the dose if you don't really look at the patient.

 shecatar 

And with regards to double checking two people should check the chemo and two signatures will sign it.

 janet558 

We always double check with another nurse as well as with the patient.

 olsenmi 

There are articles that discuss evidence related to bar coding and reductions medication errors.

 steph199 

We check BSA and the reference med dose with 2 sources and then when pick up at pharmacy check, pt name and number and dose with pharmacy then 2 RNs check same info once in med room and then at pt's bed side reading pts arm band.

 mlyne 

Do you have those references?

 shecatar 

We have a chemo protocol here…

 shecatar 

…For every chemo regimen

 janet558 

What about patients who are on study? How do you double check them?

 olsenmi 

I agree with the statement about IT folks and physician order entry. I am working on POE initiation right now and dealing with the same issues.

 shecatar 

Physician’s entry?

 olsenmi 

We meet frequently during the building of our ordersets in POE to come to a common language.

 olsenmi 

I can post references to the transcript tomorrow regarding bar coding.

 mlyne 

What are the most frequent types of errors that you see?

 Laurl at ONS 

POE= physician order entry

 shecatar 

I see

 mlyne 

How so for POE?

 shecatar 

Here we every regimen and those who are new there is a chemo protocol already made….

 olsenmi 

For study patients we double check everything in the same manner. We also verify presence of consent and verify all study drug dosing on orders with protocol.

 shecatar 

…And we base on that sheet,

 shecatar 

No need for the physician to write what chemo drugs.

 olsenmi 

Mlyne, what is your question about poe?

 marvin1379 

We check vs the IRB approved, most recently revised protocol.

 mlyne 

So you are saying that Nursing is the last safety check and you check the protocol for the study?

 mlyne 

I thought you said that POE was the most frequent chemo error? Maybe we are addressing two threads?

 janet558 

We have research nurses in our building. They meet with the patient prior to each treatment, as well as follow up with them after treatment. We do not always see the protocol because we do not have paper charts.

 Laurl at ONS 

mlyne- Mikaela is answering ...hang on...

 olsenmi 

We see many near misses related to dosing, sometimes labeling and calculations that are wrong because of patient data that is not current, such as height and weight. We use a 10% variance rule.

 dfritz 

I think sometimes the number of screens and add-ons (increases complexity of POE) that physicians have to plow through to put in a chemo order can result in errors. Just had one recently with the complex dosages (varying pill dosage and numbers of pills) of Temodar. Order entry incorrect, but was within dosage guidelines; but pt was also receiving radiation, so dose should have been lower. MD had to make several separate entries to arrive at the total dosage.

 marvin1379 

Yes that nursing is the last check (of many). Since each protocol is different and many differ from institution policy, we have the protocol online and use the counts and other info in the protocol to check the chemo.

 mlyne 

Who can order chemo? NPs? Fellows?

 janet558 

We verify ht and wt with each new patient. The pts are then seen by the Dr on a regular basis, but we do not consistently recheck this info unless we visibly notice a change….

 olsenmi 

POE is an electronic physician order entry system. Are any of you using POE for chemotherapy? Yes, the person administering the chemotherapy is always the last defense against error.

 marvin1379 

A 10% weight change, a 10% BSA change, or a weight change affecting the chemo dose 10%?

 mlyne 

We use POE in the VA system

 janet558 

We use POE

 marvin1379 

Attendings mainly. Other LIPs can, but they need it co-signed from attending.

 olsenmi 

Chemotherapy at my hospital is ordered by an NP and fellows, however the attending MD must check and co-sign all chemotherapy orders before they are dispensed and double checked.

 Laurl at ONS 

LIPs?

 janet558 

I work in an outpatient clinic where we have 3 Drs. They are the only prescribers.

 marvin1379 

Licensed Independent Practitioners. NP, Fellow

 dfritz 

Hem/onc fellows can order based on lit reference so pharmacy can double check dosages.

 mlyne 

Only hem/onc fellows and NPs, though?

 janet558 

What about premeds? Nurses and the pharmacist can order premeds.

 steph199 

Docs only

 mlyne 

Docs only

 dfritz 

Well, if you're talking about chemo for non-oncologic reasons, renal and neuro or other specialty can also order chemo for their patients. I don't really want to go there. It's the bane of the oncology nurse existence.

 olsenmi 

There should be an agreed upon standard for frequency of weight and height checks. This is very important as our pts may gain or lose weight suddenly. We double check height and weight with each visit!

 dfritz 

In our system, the ht and wt is taken the day of and prior to each clinic or infusion center visit.

 marvin1379 

But where do you look for the 10% change? Weight only, BSA, or ultimate dose?

 olsenmi 

Yes, non oncology chemotherapy is a challenge. We still require an attending signature even if it is a non oncology service.

 janet558 

Is the 10% from baseline or most recent visit?

 mlyne 

We teach the nurses that ht and weight has to be current. Difficult sometimes.

 dfritz 

At our facility, the 10% applies to dosage variance from an established wt--rounding doses, essentially.

 mlyne 

Our standard for care is the ONS chemo/biotherapy book 3rd edition.

 olsenmi 

We look at the final dose and determine whether there is a 10% variance.

 marvin1379 

The weight change needed to change the chemo dose 10% is huge!!!

 janet558 

What about oral chemo? How are those managed?

 dfritz 

Sorry, I misspoke--an established BSA (although some chemo is based on wt [kg] only).

 shecatar 

Here we base wt (KG)

 olsenmi 

It really depends upon the dose. In my experience even a slight height or weight change can cause issues with staying within 10% in some patients.

 mlyne 

In a really busy chemo clinic, what is the key to avoiding med errors? Rituals?

 janet558 

So do you weigh your patients prior to each treatment if not seen by a Dr the same day?

 olsenmi 

Also, an important point. We all should be getting our weights and heights in kg and cm.

 dfritz 

Yes, ANY visit to hem/onc physician or infusion center.

 shecatar 

Ht?

 marvin1379 

No. We just altered that policy. Weight prior to MD visit only.

 janet558 

ht = height

 mlyne 

Do you use Pepid as an assist for the nurses?

 shecatar 

How about those adult we don’t measure their ht?

 shecatar 

Every time they go for chemo right?

 janet558 

How do you calculate BSA?

 olsenmi 

Our oral chemotherapy drugs are also double checked in the same manner with the same rigor.

 Laurl at ONS 

Great questions! Whew! You guys are fast! Mikaela will answer in order!

 dfritz 

Every time they go for chemo or physician visit--height and weight.

 shecatar 

Here we multiply ht and wt and divided by 3600 and get the square root.

 janet558 

We don't always see the pts on oral chemo in our facility. If you work in an infusion area, when do you see these pts?

 olsenmi 

Redundancy is very important. Having the same safety checks in place for each drug and each provider.

 shecatar 

We get the surface area here and the surface we multiply available dose to the surface area.

 dfritz 

Our issues with oral chemo are they are given all over the hospital by nurses who are not ONS chemo providers. Don't have enough chemo nurses to go all of those places.

 olsenmi 

Yes, it sounds like many of us on the chat do obtain a weight and height with each visit. I definitely think this is the most prudent approach.

 mlyne 

Do you do safe handling competencies with all staff that take care of patients on chemo?

 janet558 

So oral chemo pts are not regularly followed by the same Drs? Who is responsible for monitoring the oral chemo?

 shecatar 

Yeah who?

 shecatar 

Especially those take home oral chemo?

 dfritz 

I do instructions with staff on the unit where the oral chemo patient is housed. Also post a chemo precautions sign which has instructions for handling pt/linen/body fluids.

 janet558 

What about side effects, reactions, etc. with oral chemo? Who is routinely seeing the pt?

 shecatar 

its too difficult here especially with the culture

 olsenmi 

I don't use pepid, do any of you use this download? I utilize the PEP cards on a daily basis and the ONS book "Improving Oncology Patient Outcomes" includes all of the pep cards and is well worth the money.

 dfritz 

Yes, the oral chemo patients ARE followed by hem/onc ... just not followed in the infusion clinic. That's part of the issue: not as much contact with health care providers.

 marvin1379 

One of our physicians has become frustrated with the chemo nurses asking about weight changes, so he has now taken on the practice of "Flat Dosing" all of his chemos/bio. In other words, after a couple of treatments, we know if the normalized dose multiplied by the BSA is tolerated, then he just writes orders for a flat dose, just the total dose. No normalized dose. Thoughts?

 mlyne 

We use Pepid online for the nurses so that they have a 24/7 access to all the info that is in the ONS chemo book and all the calculators. Books get lost on an inpatient unit and then it would be difficult to follow the safety checks.

 shecatar 

I think we really need to weigh pt right?

 olsenmi 

Yes, every time our patients come to receive chemo we get a height and a weight again! Adults and pediatrics!

 shecatar 

We don’t rely on the previous dose.

 janet558 

Is pepid on the ONS webpage?

 mlyne 

We would not give a dose that was just a dose with no unit dose. Couldn't verify it.

 marvin1379 

That's the problem we are having.

 olsenmi 

BSA can be calculated by multiplying the height in CM times the weight in KG and then dividing it by 3600, then take the square root of that.

 janet558 

We don't rely on previous dose. We look at it to see if it has changed and if so, why, but do not rely solely on it.

 mlyne 

Pepid is referred to on the ONS page -- they partnered with ONS. Great site - about $150 a year.

 marvin1379 

What is the daily patient volume on your infusion centers?

 shecatar 

here 250 mls

 olsenmi 

Yes, all patients handling hazardous drugs receive special training on safety precautions.

 dfritz 

Online BSA calculators can be put on your desktop for easy reference. Just google "BSA calculator." The first one to show up is the one I use. (Editorial note: Always be certain of the reliability and validity of any web source that you utilize. Some sites may not be able to provide evidence of their accuracy).

 janet558 

We see about 40-50 pts per day, however we also give fluids, antibiotics, iron, and arthritis meds.

 shecatar 

Depends on drugs

 mlyne 

Re safe handling -- do the staff (RNs, LPNs, NAs) receive safe handling training?

 marvin1379 

Sorry...let me rephrase. How many patients per day?

 janet558 

We only use RNs and we all have to have safe handling training

 Laurl at ONS 

Guys, can we give Mikaela just a few minutes to catch up? She is trying to address each question - thanks!

 olsenmi 

Regarding flat dosing. That doesn't sound like it is in the best interest of the patient. Prescribers should be aware that are safety checks are necessary in order to keep the pt safe.

 Laurl at ONS 

RE: Pepid- go to the Research section of www.ons.org - Putting Evidence Into Practice - all there.

 steph199 

Only RNs administer chemo but LPNs and CNAs are taught safe handling of urine, stool, emesis, etc.

 dfritz 

If your safe handling question is in relation to oral chemo, no, they do not receive the safe handling training that the infusion nurses get. The issues are not quite the same.

 olsenmi 

We actually have some physicians who thank us whenever we call for a dose discrepancy, I want to clone those!

 janet558 

Our policy requires that we have at least one Dr in the building during chemo infusions. They are very accessible and easy to ask questions of. We truly have GREAT docs and allow us all to work as a team.

 olsenmi 

We can see over 100 pts a day.

 mlyne 

Those physicians should thank you -- you are the last safety check....and I know that you folks at JH (Johns Hopkins) are great!

 dfritz 

Another issue with our POE system is that there is a cut and paste function for the chemo orders (it's too complicated to elaborate). Unfortunately, dates may be from the last round! The oncology pharmacist usually catches all the cut & paste errors.

 janet558 

Does each facility have an oncology pharmacist or are some still mixing their own drugs?

 olsenmi 

Oral chemotherapy requires safe handling and presents many challenges. We do train nurses that handle ANY hazardous drugia any route about the risks. We especially teach them about not crushing, mixing or manipulating oral chemotherapy outside of a biologic cabinet.

 mlyne 

We have a couple of chemo pharmacists in our facility.

 shecatar 

Hmmm... regarding with that in my place in Philippines.

 shecatar 

specially in my region we don’t have a onco pharmacy

 shecatar 

Nurses are the one mixing the chemo.

 steph199 

No chemo pharmacists at our hosp.

 olsenmi 

We are dealing with the cut and paste function in our POE system also. Our staff is trying to build safety mechanisms into it that will prevent the prescriber from just carrying forward old info without verification.

 Laurl at ONS 

With next answer we believe Mikaela is caught up - if we missed your question, please ask again! If not, ask away!

 olsenmi 

We only have pharmacists mixing chemotherapy at this time. I do speak with many nurses when I teach chemo courses that mix chemotherapy. The challenge is how to mix chemo and administer chemotherapy AND still do all of the double checks independently.

 janet558 

I wondered about that too? Who orders the drug? It sounds like the nurse is truly the one person with a lot of responsibility and the greatest chance for error.

 shecatar 

Speaking of administration how do you admister like doxorubicin via iv push or iv drip?

 mlyne 

What is the minimum physical space you recommend for an outpatient clinic -- per recliner?

 janet558 

We do IV push

 shecatar 

What is the best (admin route?)

 olsenmi 

Yes, I always feel that the nurse has a huge responsibility! This is why proper training and education for those giving chemotherapy is so important.

 marvin1379 

IVP

 shecatar 

iv push with ongoing normal saline on the main line?

 mlyne 

Doxorubicin?

 steph199 

IVP depends on the drug

 janet558 

If you are mixing your chemo drugs, do you have a pharmacist or someone you can call with questions?

 shecatar 

Yes, doxorubicin

 marvin1379 

Yes, and check for blood return every 1 ml

 olsenmi 

We administer ALL vesicants using the IV side arm technique. The ONS guidelines have specific recommendations about IV side arm or IVPB that should be followed.

 dfritz 

At our hospital, we have pharmacists crawling all over the place! It's amazing. We're fortunate to have an oncology trained pharmacist (Pharm.D) and another Pharm.D. who is hired as an oncology pharmacist with on the job training.

 janet558 

IV side arm?

 olsenmi 

I don't know the answer to the physical space question, do any of you know?

 shecatar 

In Philippines it is given IV drip mix with 300 normal saline.

 janet558 

Over what amount of time?

 shecatar 

Sad to say in Philippine gov’t hospital there is no oncologist pharmacist

 shecatar 

Nurses who are mixing and giving it

 olsenmi 

IV side arm is a technique where you use a free flowing IV (Normal saline or a compatible solution) and at the closest port to the patient you administer your IV push vesicant. The main principles are IV dilution constantly during your push, and frequent blood return and site checks.

 janet558 

Thank you. Yes, this is the method we use.

 mlyne 

Do you use a stopcock and separate syringe to check blood return or your vesicant syringe?

 shecatar 

You mean if it is side arm it is IV drip?

 olsenmi 

Shecatar- please refer to the ONS guidelines for IV piggyback vesicant administration. This can be dangerous if the pt is left unattended and blood return checks are not done frequently.

 shecatar 

In Philippines? No stopcock…

 janet558 

We do not use stopcock or separate syringe.

 shecatar 

….in gov't hospital…

 olsenmi 

Continuous infusions of vesicants should never be given unless through a central line with positive blood return.

 marvin1379 

Blood return check: vesicant syringe

 shecatar 

no

 shecatar 

Ordinary syringe

 shecatar 

It is really depressing

 olsenmi 

Side arm means you push the vesicant through a side port of a free flowing IV allowing for the normal saline fluid to dilute your slow push of the vesicant during administration. You then check blood return every 2cc.

 mlyne 

Our vesicants come in such large syringes and the aspiration psi seems like it might pull too much for a peripheral site.

 shecatar 

Yeah in Phil they just give it in one line mixed with 300 ml sol’n.

 janet558 

We occasionally give vesicants through PIV, but try to instruct our pts on getting a power port.

 olsenmi 

I do not advise the use of stopcocks. Some stopcocks when turned off to the pt actually do not allow the free flow of NS which you do not want.

 shecatar 

No 2nd line?

 dfritz 

Someone asked earlier about ways to prevent chemo errors . . . I think well-educated and experienced chemo nurses are key. Also, developing a process with the pharmacy and adhering to it RELIGIOUSLY. I have seen errors mostly when processes were circumvented or short-cutted.

 olsenmi 

We use the syringe that contains the vesicant to pull back gently to check blood return. This seems to work well for us. We actually use a closed system drug transfer devise on our IVP vesicant syringes to prevent exposure and it works well with blood return checks.

 mlyne 

Phaseal?

 olsenmi 

Yes we do use phaseal

 janet558 

Phaseal?

 mlyne 

Does it lower the aspiration psi on the big syringes?

 shecatar 

You  no need with 2nd line? And using stopcock?

 marvin1379 

What is Phaseal?

 olsenmi 

RE lowering aspiration psi: Not that I know of mlyne.

 olsenmi 

Phaseal is a closed system drug transfer devise to prevents exposure of chemotherapy during administration. There is more information on their website if you google it.

 Laurl at ONS 

You guys may want to also check out the last years' hot topic transcripts on safe handling- "Past dates and transcripts".

 janet558 

Is anyone giving thiotepa?

 dfritz 

We had a couple of physicians who liked it for pleurodesis.

 olsenmi 

We are not giving thiotepa anymore.

 shecatar 

And what is a vesicant syringe? Look like ordinary syringe?

 janet558 

What are you giving for bladder ca?

 mlyne 

I was just referring to the syringe that comes from the pharmacy with the vesicant drug in it.

 janet558 

We use 60 cc syringes for our doxu - depending on dose

 dfritz 

Bladder ca: gemcitabine--in a research protocol post-TURBT

 Laurl at ONS 

Also check the June 08 Vascular access chat transcripts- a lot of this info re: vesicant administration is there as well.

 olsenmi 

For IV side arm technique we use one set of primary tubing and hook it directly to the hub of the catheter or the PIV. The syringe is usually any size syringe and not different that what you usually use for other meds.

 dfritz 

Bladder ca: Also have done mitomycin for post-TURBT

 olsenmi 

Do you all include the patient in your safety program...ensuring that they have a written treatment plan, know their drugs, doses, etc.

 mlyne 

We love the chemo handouts from U Pitt Medical Center

 Laurl at ONS 

We are about 3-4 minutes from the end of our chat - thank you so much - if you have a last question, now's the time!

 janet558 

We have a pt teaching visit prior to starting chemo. The pt will visit with a chemo nurse who reviews all medications, treatment plan, what the day will be like, side effects, who to call and when.

 marvin1379 

We will receive an emailed link of the transcript?

 olsenmi 

A great strategy for decreasing errors is to ensure pts are educated and feel a part of the team, comfortable speaking up etc.

 dfritz 

The teaching visit is difficult for patients who come from a distance. We have pts from 2 states away (Montana coming to Denver).

 Laurl at ONS 

Transcripts are all posted on the www.ons.org - CNE central tab- Click index - then chats- Hot topic web page- Current date and chat. Should be posted tomorrow!

 mlyne 

Thanks so much for a great chat!

 olsenmi 

We also need to be cautious of our words. Patients often hear staff calling drugs many different names...generic, trade, and nicknames e.g Adria. This is confusing to patients.

 Laurl at ONS 

If you didn't get a chance to talk (or aren't ready to quit!) tomorrow is our last chat on this topic with Mikaela - it's at 11:00 am Eastern time - please join us then.

 Laurl at ONS 

We are unfortunately out of time - many thanks for a terrific, lively discussion on this important topic. Thank you Mikaela!

 marvin1379 

Thanks Mikaela and everyone!!!

 marvin1379 

Doesn't AZ differ with daylight savings>

 Laurl at ONS 

THANK YOU to all of you for your great participation

 shecatar 

thanks a lot

 shecatar 

thanks

 shecatar 

I’m working here now in military hospital.

 shecatar 

We will hope to talk to you next time and to learn from you guys

 Laurl at ONS 

Many thanks!