Strategies for Preventing Chemotherapy Errors

 Laurl at ONS 

Welcome to today's Hot topic chat - today's speaker is Mikaela Olsen, who will talk to us about prevention of medication errors. Welcome Mikaela!

 olsenmi 

Hi everyone! Do any of you want to start us off by asking a question related to medication errors?

 olsenmi 

This is our third chat and we have had some interesting conversations about medication safety culture, who signs chemo orders, what do the safety checks consist of etc.

 olsenmi 

Ok, where are you all from?

 pavila 

Indiana

 lkrioux 

Charlotte, NC

 Julie Marshall 

Charlotte NC

 lkrioux 

Hello Julie and Shannon!

 olsenmi 

Wonderful! Is there anyone from outside the U.S.?

 jennifer webster 

Georgia Cancer Specialists, Atlanta, GA

 Laurl at ONS 

Last night we had someone from Saudi Arabia...interesting perspectives!

 olsenmi 

What chemotherapy errors do you all see most commonly in your practice?

 pavila 

Incomplete orders or the use of unapproved abbreviations.

 olsenmi 

Are your orders for chemo handwritten or preprinted?

 Julie Marshall 

Lack of premeds and appropriate hydration.

 pavila 

We have many ordersets that have to be filled in for certain areas.

 Tammy Easterly 

Tennessee oncology, Nashville, TN

 rnmsw 

Carilion Clinic, Roanoke, VA

 Julie Marshall 

Preprinted order form with hand written orders.

 olsenmi 

Julie, are your orders handwritten by the prescriber?

 Julie Marshall 

Yes

 schubu77 

Chicago, Illinois---- how do you handle incomplete orders from physician?

 Julie Marshall 

We call physician for clarification and have them rewrite the order if incomplete

 Tammy Easterly 

What is the most common reason a nurse gives regarding a med error?

 olsenmi 

It is a tremendous amount of work to develop preprinted orders for each regimen however it is worth the effort for safety and to prevent omissions.

 olsenmi 

You should never accept incomplete orders from the physician for chemotherapy.

 schubu77 

We frequently are asking physicians to re-do orders.... physicians at times are angry we interrupt them to clarify... very frustrating for us.

 olsenmi 

Many medication errors we see are related to dosing, height, weight, calculations. Our safety checks require that nurses double check all calculations using their own source data prior to administration.

 rnmsw 

How do you decide which regimens to develop standard orders for and where do you get the info to develop the order sets?

 olsenmi 

Yes, it is extremely frustrating when our MD colleagues do not value our safety checks and when they are not open to communication regarding problems with chemotherapy.

 Julie Marshall 

Our safety checks include two nurse double check as well

 lkrioux 

Our challenges in Charlotte are incomplete orders. Slows process and delays treatment.

 rnmsw 

Our double checks include two nurses to check the orders before noting, two nurses to check each dose before administration, and a triple pharmacy check when entering the orders

 Tammy Easterly 

Since going to EMR, we rarely have incomplete orders any more.

 rnmsw 

Tammy, which EMR system do you use?

 schubu77 

Who mixes drugs and how are they checked prior to administration? Not every facility has pharmacists.

 khetzler 

Lahey Clinic, Burlington Mass Our question is how to administer chemo using electronic med administration system.

 Tammy Easterly 

EMR= Aria

 olsenmi 

At Johns Hopkins we have over 200 preprinted orders, it has taken us a number of years to develop them. If there is a national standard of care we utilize those references. Otherwise we meet with our interdisciplinary team to develop an institutional standard.

 olsenmi 

NCCN has also developed preprinted orders.

 rnmsw 

I haven't found NCCN to have preprinted orders, just regimens. Am I looking in the wrong place?

 schubu77 

We have EMR system... orders still wrong. Anyone use Beacon?

 olsenmi 

When a pharmacist is not available for mixing chemotherapy it is very important that the nurse mixing is not the only person available to administer the drugs. This would not allow for double safety checks that are vital to safety.

 rnmsw 

I would also be interested if anyone is using Beacon. We are considering it and I am hearing that the pharmacists don't like it.

 lkrioux 

We have discussed adopting some of the NCCN order templates for those regimens most commonly used. We currently do not have standardized forms; they are paper, fill in the blank.

 olsenmi 

khetzler, can you elaborate on your question so I understand it fully, thanks!

 olsenmi 

My understanding is that the NCCN ordersets are for purchase.

 schubu77 

We have pharmacy tech most of the time. 4 nurses available to check. Lots of double checks… still some errors... something is wrong with our system.

 rnmsw 

schubu77-Are your checks true independent double checks?

 olsenmi 

schubu77 what kinds of errors do you see most commonly?

 khetzler 

We are soon to be using an electronic med admin system. We understand that sequencing pre-meds and chemo can be a challenge. Are any inpatient units administering chemo using electronic med admin?

 lkrioux 

We recently had an error that involved pharmacy labeling of the drug. Label indicated volume and not drug dosage. the nurse called to verify and was given verbal clarification, but the patient ended up received 5 times the prescribed dose.

 jennifer webster 

Some of you may want to look at the website ChemoOrders.com. It has common regimens based on dx, stage, etc. and you can develop pre-printed orders from it. There is a "flash demo" you can look at to decide if it is what you want. The whole website is free by the way.

 olsenmi 

The double checks should be independent checks! I teach nurses that are the 2nd check RN to take their time and independently verify all labs, ht wt, calculations etc.

 khetzler 

The system we will be using is Carefusion. It schedules doses and reads wristband bar codes and drug bar codes.

 olsenmi 

Lahey clinic- do you have physician order entry that feeds into your electronic MAR and do you schedule things yourself or does pharmacy?

 lkrioux 

olsenmi: we also encourage independent checks of all components: BSA, lab verification, dosing, etc...

 rnmsw 

We are using EPIC for charting and med administration, but our chemo orders are still on paper. I am looking at beginning to develop standard ordersets to enter into the EMR.

 khetzler 

Pharm enters orders from paper original. Pharm schedules. We request them to change times.

 olsenmi 

Yes, labeling errors are not uncommon. If the chemo is not properly labeled it should go back to the mixing area and be properly labeled. We should not fix labeling at the bedside.

 khetzler 

No POE at Lahey yet. Coming later.

 schubu77 

We do independent double checks with orders and checking solutions/drugs after mixed by the pharmacist. Problem stems from regimen confusion, solution chosen or not specified, and scheduling.

 rnmsw 

shubu77-Are you inpt or outpt?

 schubu77 

Outpatient

 rnmsw 

Do your MDs give you the regimen they are using when they order the chemo?

 olsenmi 

When pharmacy schedules it is always a challenge because the RN is the one who really knows the timing of everything. We are getting ready to roll out a physician order entry system where our nurses will be doing the retiming so I will be curious to see if this helps us out.

 lkrioux 

We request a reference for non-standard chemo regimens. The problem is getting them to do this. Pharmacy spends an exorbitant amount of time trying to find references.

 schubu77 

Because of all errors, they have started to give regimens. Getting better.

 rnmsw 

We do also. We insist on a regimen if it is not in a reference the pharmacist, me or the charge nurse spends quite a bit of time tracking down references, but we will not give chemo without either a reference or knowing that it is on a trial of some type.

 olsenmi 

last night I referred to our chemo checklist that we use for safety checks. We also require a reference for any nonstandard regimens and if the ref does not exist or does not match the diagnosis, drug doses etc then we require two attending MD signatures. The checklist will be available on the transcript.

 rnmsw 

MDs have not been happy at times, but they have gotten used to this as our standard and we have written it into our chemo infusion policy.

 olsenmi 

Having a strong protocol supported by leadership and a checklist can ensure that safety checks are done the same way each time. MDs eventually get used to these rules and the complaining lessens over time when they know we will not budge.

 khetzler 

Olsenmi: What EMR are you using for POE?

 olsenmi 

We are on year 9 of our checklist and protocol and MDs automatically bring the reference with the chemo orders because they know...it is not going anywhere without it.

 lkrioux 

Our biggest problem is always physician compliance (completing order forms completely and correctly). And then who has to call the MD for clarification: RN or pharmacy.

 olsenmi 

We use sunrise POE and it has an EMAR with it.

 schubu77 

I agree with having a strong leader to enforce safety protocols, I think that is where we are lacking. Do nurses do the charging at your facilities? w

 lkrioux 

Nurses charge in our outpatient dept.

 olsenmi 

we do our safety checks on the pharmacy side and nursing side sometimes simultaneously so hopefully we are both catching things and calling for clarification but sometimes it gets by pharmacy and nursing catches the problem and calls the MD.

 khetzler 

Lahey ambulatory heme/onc is also nurse charging.

 olsenmi 

In our outpt facility our RNs do the charging.

 rnmsw 

MD compliance is an issue, no doubt, but someone does need to function as an advocate for the patient. I feel since I am the one administering the chemo it is up to me to make certain it is correct and I know it is correct before I give it. Sometimes Nurses call and sometimes pharmacy calls.

 lkrioux 

Amen sister!

 olsenmi 

Great advice RNMSW!

 khetzler 

Any advice on staff development for mixed med-surg onc unit? Administering 5-10 treatments proves challenging to keep up competence.

 khetzler 

5-10 treatments per week that is on a 35 bed unit.

 schubu77 

Are Zometa/Aredia on separate orders if patient does not receive them on same days of chemo? Ours are not. Do the nurses decide scheduling or physicians?

 olsenmi 

Nurses who administer chemo should receive didactic and hands on training. It is definitely challenging when the volume is high but the risk is low. You could consider training a subset of nurses who are the chemo nurses and ensuring you have 2 staffed each shift but that can be challenging also.

 rnmsw 

We do monthly written in services on oncology related topics-onc emergencies, new drugs, types of cancers, etc. plus I do a skills check off and a competency test annually. In addition, all our nurses carry a current ONS Chemo Provider card and are required to renew biannually.

 olsenmi 

We do not have Zometa on our chemo orders, it is a separate order.

 khetzler 

Thanks for those suggestions.

 rnmsw 

Any order that is not a chemo or is not administered timed around chemo (premeds and hydration) are not put on our chemo orders (we are inpt.)

 Julie Marshall 

In an inpatient setting, do you require a chemo competent nurse to administer oral?

 lkrioux 

We include all meds that are part of the regimen on the chemo order sheet. that includes premeds, postmeds, hydration, protective agents as well as growth factors.

 olsenmi 

If supportive care meds are not included on the chemo orders the nurse has a lot of responsibility to ensure none of the supportive care meds are omitted. e.g. leukovorin with methotrexate, hydration, appropriate antiemetics etc.

 lkrioux 

What about administering cytotoxic agents for nononcologic purposes. Do you follow the same process?

 rnmsw 

No. There are too many places to administer and we cannot cover all over the house. We have over 700 beds. We have just put out an oral hazardous drug policy. There are many other drugs besides chemo that fall into this category, too. We tried to highlight that by putting out the policy.

 olsenmi 

we require chemo training for anyone who administers chemo of any kinds. We also require them to do the chemo checklist prior to each dose.

 lkrioux 

olsenmi - can you elaborate on your chemo training?

 khetzler 

We also end up floating chemo provider nurses to an ICU or step down setting just to administer chemo. Staff RNs on other units request a nurse from us sometimes for a non-onc chemotherapy

 rnmsw 

Sorry, obsenmi, we do include rescue drugs, lasix, etc. on the order set too. If it is related directly to the chemo administration, especially if it is timed with the chemo, we it is ordered on the chemo orderset.

 khetzler 

Moderator: will transcript include contact info of participants?

 olsenmi 

Our oncology nurses go through a 4 hour class initially and do self learning modules in addition on hazardous handling and chemo safety checks with tests. They then sit for a chemo exam. Once they pass the exam they have to complete their competency checklist which includes hands on administration with a preceptor. They receive annual competency after that. In addition at 6-12 months they attend the ONS chemo bio course.

 Laurl at ONS 

RE: transcript- no, you are all anonymous, even to us! If you'd like to get a message to Mikaela, send it to me at lmatey@ons.org

 khetzler 

Lahey non chemo provider staff RNs are trained in safe handling so they do administer orals.

 rnmsw 

kheltzler-how do you train those non chemo provider staff RNs?

 khetzler 

Working on it

 rnmsw 

Are you training house-wide?

 lkrioux 

We have been challenged recently with administration of chemo in off-oncology areas such as Radiology, OR, etc... How do you handle training these staff members? We are focusing most of our attention on safe handling issues.

 Laurl at ONS 

Just FYI - ONS now has a trainer course for how to teach administration of chemo in the non-chemo setting - called Treatment Basics. There are about 25 trainers "out there" now - another trainer course this fall. Info on CNE central of ONS.

 olsenmi 

We have a chemotherapy administration self learning module that non-oncology staff complete and we also do hazardous drug handling education. We also offer the ons chemo bio course twice yearly and invite nurses from all over the hospital that qualify.

 Laurl at ONS 

We plan to have this trainer course also as an online course soon.

 lkrioux 

How does everyone handle ongoing competency validation in their areas?

 schubu77 

Outpatient RNs: Do your physicians see the patient the same day they receive chemotherapy?

 lkrioux 

olsenmi - How would nurses qualify for the ONS course?

 khetzler 

Wow! Treatment basics. We will definitely check that out.

 olsenmi 

We have annual competency that includes hands on self demonstration by each employee as well as, review and verbal demonstration of safety checks. We also, use this time to discuss errors, near misses and our med error culture and any issues.

 olsenmi 

our pts do not always see the MD on the day of chemo admin.

 lkrioux 

slsenmi - we have a similar process. We use mock administrations. Does anyone require live demonstrations and if so, how often. What do you do with the night staff or staff that administer chemo once every 6 months?

 khetzler 

Participants with yearly competency: Are you willing to share your materials as attachment to the transcript of this discussion?

 rnmsw 

I would be willing.

 olsenmi 

ONS chemo bio course- participants must be licensed registered nurses who have been employed as such for a min of 6 months. It is appropriate for nurses new to chemo as well as experienced nurses

 rnmsw 

obsenmi-do your new nurses administer chemo before taking the ONS course?

 lkrioux 

How would we add our documents as an attachment to this chat?

 Laurl at ONS 

If you'd like to send anything to add to the transcript please send it to me at lmatey@ons.org and we'll add it when it is posted.

 olsenmi 

We do not have live demonstrations and because we do not have a cutoff time for administering chemo our night shift RNs give a lot of chemotherapy.

 rnmsw 

We also give a lot of chemo around the clock.

 olsenmi 

Our new nurses do administer chemo after going through our 4 hour course and passing the exam and all competencies.

 lkrioux 

We have some smaller facilities within our hospital system and it is difficult to keep their competency up.

 khetzler 

Does anyone else have a cutoff time for inpatient?

 Julie Marshall 

3pm

 rnmsw 

olsenmi-can you share the outline of your 4 hour course?

 olsenmi 

I know some hospitals use a supervisor or a night shift chemo trained nurse to float and give chemo; what do the rest of you do if volume of chemo at night is an issue?

 rnmsw 

Or some topics you cover?

 Julie Marshall 

Let me clarify, must have order by 3pm but given at all hours.

 olsenmi 

Yes, I can share the outline.

 lkrioux 

We do not have nurses administer chemo until after going through the ONS chemo course and that is generally after 6 months clinical experience.

 Laurl at ONS 

Outline will be posted with transcript.

 rnmsw 

ikrioux-that is our practice with new nurses as well.

 rnmsw 

I'm interested in the way olsenmi does it though.

 olsenmi 

I like the idea of ensuring chemo orders are received early in the day so that if there are errors they can be dealt with appropriately while folks are available.

 lkrioux 

Our oncology staff (or Educator extraordinaire) will go to off units to administer chemo

 olsenmi 

the 4 hours is a very very basic intro to chemo and the various drugs, with a lot of theory behind chemo and administration issues.

 lkrioux 

The reason we have a cutoff time for chemo orders is because our chemo trained pharmacy staff who mix chemo leave at 3:00. If the orders are for emergent needs, they will still mix if after the 3pm deadline.

 olsenmi 

Our orientation program provides separate days and lectures on symptom management. So, this course is limited.

 olsenmi 

Every nurse at JHH is required to hold an ONS chemo provider card.

 lkrioux 

Can anyone share their favorite chemo references/resources their nurses use on the units?

 rnmsw 

UptoDate is becoming my recent favorite. One of our oncologists showed it to me.

 pavila 

Olsenmi - does the hospital reimburse or use incentives for the RNs to have the chemo provider card?

 khetzler 

Chemoregimen.com is used, but it doesn't tell you who's behind the info? (Editor’s note: always verify the reliability and accuracy of any web-based materials that you utilize, including web-based calculators or regimens).

 lkrioux 

Are their any pharmaceutical companies still offering text references for nursing use?

 olsenmi 

The new 2009 Chemotherapy and Biotherapy Guidelines and Recommendations is one reference that should be available everywhere nurses give chemotherapy or biotherapy drugs. It is very up  to date with new drugs.

 Laurl at ONS 

Great discussion everyone - we have about 5 more minutes- please ask that last question if you have one!

 olsenmi 

RE: incentives: we pay for them to attend the course and for renewal reimbursement. Our director is very dedicated to ensuring we meet this goal.

 khetzler 

We like Wilkes and Barton-Burke Onc Nursing Drug Handbook.

 khetzler 

What about books with on-line supplement once you buy the book?

 lkrioux 

The one thing about the ONS Guidelines Book is it doesn't give dosing or frequency.

 olsenmi 

Yes, due to the fact that there are so many different dosing and frequency regimes for different drugs we do not include them in the guidelines. It is not a drug reference book.

 olsenmi 

Books with on-line supplements or updates are a great resource.

 khetzler 

Know any?

 lkrioux 

We recently added the ONS Emetogenic Tool for our nurses to make sure MDs were ordering appropriate antiemetics. Love it!

 rnmsw 

ikrioux-is this an actual Tool you are referring to? Or is this the training given in the course?

 Laurl at ONS 

Unfortunately, we are out of time! Many thanks for your lively discussion! Please check back at www.ons.org for the next chat series, starting in a couple of weeks! It is on palliative care.

 Julie Marshall 

chemocare.com is also great for education

 lkrioux 

Emetogenic: it’s a tool. Shannon, can you share where you found the tool?

 olsenmi 

If you are using online web references for dosing or teaching patients it is important to ensure that the site is credible, evidenced based and all dosing and recommendations have been validated. There have been many errors from prescribers using references that are misprinted, or outdated.

 lkrioux 

Good point

 Laurl at ONS 

Thank you Mikaela for your talk today! Have a great day everyone!

 olsenmi 

Thank you so much! This has been a great CHAT with many interested folks. I hope we can do this again!

 rnmsw 

Great chat!