How should information be presented in the medication order to minimise errors?

From Cancer Guidelines Wiki

Introduction

Errors in the prescribing and ordering of cancer therapy are one of most common medication errors occurring in cancer therapy. Illegible or ambiguous prescriptions and the use of inconsistent terminology and unrecognised abbreviations lead to misinterpretation of medication names, doses and dosage instructions and increases the potential for errors.[1][2][3][4][5][6][7]


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Evidence Summary

Standardisation of the prescribing process and associated documentation reduces the likelihood of prescribing errors in cancer therapy.[8][3] Presenting a medication order in a clear, consistent and unambiguous manner minimises the likelihood of misinterpretation of an order or prescription by pharmacists and nursing staff.

Using a standardised or pre-printed order form template specifically designed for use in cancer treatment and with input from prescribers, pharmacists and nursing staff assists in standardization.[8][9][10][11] The use of electronic systems to facilitate the prescribing of cancer therapy has also been demonstrated to improve safety.[12][13][14][15][16][17][3]


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Recommendations

Consensus-based recommendationQuestion mark transparent.png

The following guidance is in addition to the legislative requirements of State/Territory Health regulations (Drugs and Poisons). (Carrington et al, 2010b; Goldspiel et al, 2015a)

  • The medication chart should be designed specifically for the purpose of prescribing chemotherapy, targeted therapy and supportive medication.
  • All known medication allergies must be recorded on the order and if no allergies are reported by the patient then ‘nil known allergies’ should be recorded.
  • The chemotherapy chart should be used to prescribe all parenteral and oral medications used in the treatment of cancer and should be approved by the facilities Drug & Therapeutics committee (or equivalent) and medical records/forms committee.
  • Sufficient space should be available to allow a clear description of the medication, date and time of administration, the dose, route and frequency without unnecessary abbreviations.
  • Sufficient space should be available to allow the signatures of the prescriber, pharmacist and nurse.
  • Prescribers should avoid the use of handwritten prescriptions (medication AND doses) with the use of pre-printed or computer generated orders being preferable. Where handwritten orders are unavoidable the order should be PRINTED using permanent black ink.
  • Verbal orders for the initiation of cancer therapy should not be permitted under any circumstance.
  • Where a copy of a chemotherapy order is to be sent to an offsite location it should be scanned not faxed. Faxing produces a poor copy of the original and can result in errors where lines obscure decimal points or where dosage details appear incomplete. Carbon copies should not be used.
  • A PBS script alone should not be used to prescribe chemotherapy by any route as it has insufficient space to provide the information required to ensure safe dispensing. An order written on an appropriate chemotherapy order chart should accompany a PBS script.

Physical and staffing resources should enable the prescriber to complete an order away from distractions and interruptions to maximise safety.


Practice pointQuestion mark transparent.png

Some electronic prescribing programs may use abbreviations that are not considered best practice (Australian Commission on Safety and Quality in Health Care, 2011a; Australian Commission on Safety and Quality in Health Care, 2011b). This should be taken into account when choosing and implementing electronic programs.

(Carrington et al, 2010b)[1] ;(Goldspiel et al, 2015a)[3] ;(Australian Commission on Safety and Quality in Health Care, 2011a)[18] ;(Australian Commission on Safety and Quality in Health Care, 2011b)[6]


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Tables

Table 6: Information to be included on a chemotherapy order

Patient name and TWO other unique identifiers (e.g. hospital number, date of birth)
Patient height, weight and BSA
Medication allergies and relevant laboratory results
  • If no allergies are reported by the patient then ‘nil known allergies’ should be recorded.
Name of the protocol being used and the diagnosis
Date the treatment is to be given and the cycle number (i.e. cycle 1 of 4)
All medications to be given as part of the protocol
  • This includes targeted therapy, oral chemotherapy and supportive therapy that accompany the protocol (e.g. hydration, anti-emetics, supportive medication for home use).
  • Medicines should be prescribed using the generic name.[19][10] Trade names, abbreviations and chemical names should not be used.[20][6]
  • Care should be taken where a number precedes a medicine name (e.g. 6-mercaptopurine, 5-fluorouracil) as this can be misinterpreted as a dosing instruction. The preceding number can be omitted in most cases.
Dose per specific patient factor (i.e. X mg/m2) and the actual calculated dose to be administered
  • The rounding of doses to whole numbers or one decimal point should be considered for larger doses in adults (e.g. cisplatin 186 mg is preferable to 185.62 mg) and reduces the likelihood of overdose where the decimal point is missed.
  • Doses must be in Arabic numbers (i.e. 1, 2, 3, 4 etc.), metric units and should represent the recognised measurement of the agent. E.g. bleomycin is expressed as international units NOT mg.
  • Table 8 lists dangerous unit measure abbreviations whose use is NOT recommended.
Directions where applicable
  • Abbreviations must be avoided.[21][6][3]
  • Table 9 lists dangerous dosing instruction abbreviations whose use is NOT recommended.
Days, dates and times when each medication is to be given
  • Multiday regimens should be written in a format that specifies the dose per m2 for each day.
  • Where doses are to be given on specified days e.g. day 1 AND day 8, this must be clear to avoid misinterpretation as days 1 through to 8.[7][3]
Diluents, volume and rate of administration where applicable for each medication and fluid
  • Rates of administration should be unambiguous. For example: q24hrly can be misinterpreted as every 2-4 hours and should be written as ‘to be administered over 24 hours'.[12]
Dosage form and administration route for each medication
  • Table 10 lists dangerous route of administration abbreviations whose use is NOT recommended.[21][6]
Dose modifications for the patient according to laboratory results and side effects
The prescriber’s name, signature and the date the order was written
  • The date should be clearly differentiable from intended date of administration if the two differ.


Table 7: Dangerous abbreviations to be avoided for units of measurement [21][1][6]

Abbreviation to AVOID Intended meaning Reason for avoiding Acceptable alternative
ug or μg microgram Mistaken for milligram Write microgram in full
U or U/s unit Mistaken for 0 Write units in full
IU International units Mistaken for IV or the number 10 Write international units in full
No zero before decimal point (eg .5mg) 0.5mg Misread as 5mg Write 0.5mg or write 500 microgram
Zero after decimal point (eg 5.0mg) 5mg Misread as 50mg Do not use decimal points after whole numbers


Table 8: Dangerous abbreviations to be avoided for dosing instructions [21][1][6]

Abbreviation to AVOID Intended meaning Reason for avoiding Acceptable alternative
OD, or od d ONCE a day Mistaken for twice a day Write mane or morning, nocte or night or specific time
QD or qd EVERY day Mistaken as qid (four times a day) Write mane or morning, nocte or night or specific time
QOD Every other day Mistaken as qid (four times a day) Write on alternate days or every second day
M Morning Mistaken for n (night) Write mane or morning
N Night Mistaken for m (morning) Write nocte or night
6/24 Every 6 hours Mistaken for 6 times a day Write 6 hourly
1/7 For ONE day Mistaken for 1 week Write for ONE day ONLY in full
X 3d For 3 days Mistaken for 3 doses Write for THREE days ONLY in full


Table 9: Dangerous abbreviations to be avoided for route of administration [21][1][6]

Abbreviation to AVOID Intended meaning Reason for avoiding Acceptable alternative
SC Subcutaneous Mistaken for sublingual Write subcutaneous or subcut
S/L Sublingual Mistaken for S/C and interpreted as subcutaneous Write sublingual or under the tongue
IT Intrathecal Can be confused with IV Write INTRATHECAL in full
IP Intraperitoneal Can be confused with IV Write INTRAPERITONEAL in full


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References

  1. 1.0 1.1 1.2 1.3 1.4 Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010 Sep;6(3):220-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20887505.
  2. Academy of Medical Royal College. Achieving safer prescription of cytotoxic agents: Academy Recommendations 2015. London, UK: Academy of Medical Royal College; 2015 Available from: http://www.aomrc.org.uk/wp-content/uploads/2016/05/Achieving_Safer_Prescription_Cytotoxic_Agents_0415.pdf.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Goldspiel B, Hoffman JM, Griffith NL, Goodin S, DeChristoforo R, Montello CM, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm 2015 Apr 15;72(8):e6-e35 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25825193.
  4. Neuss MN, Gilmore TR, Belderson KM, Billett AL, Conti-Kalchik T, Harvet BE, et al. 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology. Oncol Nurs Forum 2017 Jan 6;44(1):31-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28067033.
  5. Carrington C, Stone L, Koczwara B, Searle C. Development of guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010 Sep;6(3):213-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20887504.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Australian Commission on Safety and Quality in Health Care. Recommendations for Terminology, Abbreviations and Symbols used in the Prescribing and Administration of Medicines.; 2011 [cited 2016 Sep] Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/32060v2.pdf.
  7. 7.0 7.1 Institute for Safe Medication Practices. ISMP Safety Alert. Vincristine therapy: Days “4-11” misunderstood as days 4 through 11. [homepage on the internet]; 2006 Jun 29 [cited 2016 Sep]. Available from: http://www.ismp.org/newsletters/acutecare/articles/20060629.asp.
  8. 8.0 8.1 Dinning C, Branowicki P, O'Neill JB, Marino BL, Billett A. Chemotherapy error reduction: a multidisciplinary approach to create templated order sets. J Pediatr Oncol Nurs 2005 Jan;22(1):20-30 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15574723.
  9. David BA, Rodriguez A, Marks SW. Advances in Patient Safety Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008.
  10. 10.0 10.1 Goldspiel BR, DeChristoforo R, Hoffman JM. Preventing chemotherapy errors: updating guidelines to meet new challenges. Am J Health Syst Pharm 2015 Apr 15;72(8):668-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25825190.
  11. Bryant-Bova JN. Improving Chemotherapy Ordering Process. J Oncol Pract 2016 Feb;12(2):e248-56 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26733624.
  12. 12.0 12.1 Womer RB, Tracy E, Soo-Hoo W, Bickert B, DiTaranto S, Barnsteiner JH. Multidisciplinary systems approach to chemotherapy safety: rebuilding processes and holding the gains. J Clin Oncol 2002 Dec 15;20(24):4705-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12488417.
  13. Kozakiewicz JM, Benis LJ, Fisher SM, Marseglia JB. Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry. Am J Health Syst Pharm 2005 Sep 1;62(17):1813-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16120742.
  14. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005 Mar 9;293(10):1197-203 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15755942.
  15. Dubeshter B, Walsh CJ, Altobelli K, Loughner J, Angel C. Experience with computerized chemotherapy order entry. J Oncol Pract 2006 Mar;2(2):49-52 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20871716.
  16. Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999 Jul;6(4):313-21 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10428004.
  17. Adelson KB, Qiu YC, Evangelista M, Spencer-Cisek P, Whipple C, Holcombe RF. Implementation of electronic chemotherapy ordering: an opportunity to improve evidence-based oncology care. J Oncol Pract 2014 Mar;10(2):e113-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24371301.
  18. Australian Commission on Safety and Quality in Health Care. Electronic Medication Management Systems: Specialist Functions.; 2011 [cited 2016 Sep] Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2014/01/Electronic-Medication-Management-Systems-Specialist-Functions.pdf.
  19. Schulmeister L. Look-alike, sound-alike oncology medications. Clin J Oncol Nurs 2006 Feb;10(1):35-41 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16482726.
  20. Blum M, Peck V, Seltzer T, Goldberg-Berman J. Alert: 6-mercaptopurine may be erroneously dispensed instead of propylthiouracil. Thyroid 2005 Nov;15(11):1315 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16356101.
  21. 21.0 21.1 21.2 21.3 21.4 Brunetti L, Santell JP, Hicks RW. The impact of abbreviations on patient safety. Jt Comm J Qual Patient Saf 2007 Sep;33(9):576-83 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17915532.

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