What factors should be taken into account when using electronic systems to support the delivery of cancer therapy?

From Cancer Guidelines Wiki

Introduction

Errors involving cancer therapy can occur at any stage in the ordering, dispensing, administration and monitoring of cancer medications. The ability to prepare and administer safe and accurate doses of medication relies on a robust and efficient ordering process by clinicians. Handwritten medication orders have been one of the most important paper transactions which occur in healthcare, and yet are a major contributor to preventable medication errors which arise due to illegibility, use of abbreviations, terminology misinterpretation and miscalculation.[1][2][3] The use of electronic systems to enhance the process of providing cancer therapy has become more prevalent and integrated into hospital electronic health records since the 2010 edition of this guideline.


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Evidence Summary

The use of electronic systems to facilitate the prescribing, dispensing and administration of cancer therapy has been demonstrated to improve safety.[4][5][6][7][8][9]

Electronic chemotherapy prescribing (e-prescribing) enhances the safety of the entire medication management process in clinical oncological and haematological practice, in both adult and paediatric patients.[10] Electronic systems used in the cancer setting have many potential benefits including standardisation of protocols, electronic decision support to assist with management of interactions and allergies, and provision of a complete record of a patient’s treatment history including cumulative doses of cancer chemotherapy.

The use of electronic prescribing and information management systems do not completely eliminate errors and may introduce their own specific risks as an unintended consequence.[11][12] In this regard, local governance systems should be in place to ensure accurate reproduction of prescribing information such as protocols in the electronic system. Systems require careful implementation to ensure optimal functionality and improvements in quality and safety while avoiding the introduction of new error prone processes and safety risk. Implementation of an electronic system should be overseen by an institutional governance process and facilities should seek full vendor engagement in implementing improvements to the system. If more than one system is in use or implemented for the process of prescribing, preparation, dispensing and administration then there may be a need to duplicate data entry into multiple systems. This can negate the benefits of any one system and can actually contribute to further medication errors and incomplete patient healthcare records.

A complete guide to implementation of electronic prescribing and information management systems is beyond the scope of this guideline. Useful resources include the Australian Commission on Safety and Quality in Health Care guide (Electronic Medication Management Systems — A Guide to Safe Implementation),[13] the British Oncology Pharmacy Association (BOPA) Standards for Reducing Risks Associated with e-Prescribing Systems for Chemotherapy,[11] and the "2012 ISMP International Medication Safety Self-Assessment® for Oncology" developed by the Institute for Safe Medication Practices (ISMP) and the Institute for Safe Medication Practices Canada (ISMP Canada).[14]


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Recommendations

Consensus-based recommendationQuestion mark transparent.png

Electronic prescribing and information management system specifications should ensure that all recommendations made within these guidelines with respect to the safe prescribing, dispensing and administration of cancer therapy are met. An electronic prescribing and information management system should be implemented in all institutions where cancer therapy is prescribed and ordered for adult and paediatric patients.


Implementation of an electronic prescribing and information management system should be overseen by an institutional governance process and facilities should seek full vendor engagement in implementing improvements to the system.


The implementation and operation of an electronic prescribing and information management system should include consideration of the British Oncology Pharmacy Association (BOPA) and Australian Commission on Safety and Quality in Health Care (ACSQHC) guidelines.


Practice pointQuestion mark transparent.png

Training: All staff operating e-prescribing systems must be appropriately trained and competent to perform their specific roles.


Set-up and Protocol Development: e-prescribing systems must allow stringent controlled user access for approved staff to set-up chemotherapy protocols and allow a way to build protocols and keep them in an inactivated state until appropriate quality assurance processes have occurred to enable activation and access by prescribers.

  • Chemotherapy protocols should incorporate the recommendations outlined in these guidelines including nomenclature, dosing, schedule, diagnosis and testing and allow incorporation of appropriate supportive care regimens.

Validation: Independent checking of the system once set-up is complete and for each individual chemotherapy protocol once built should be carried out by an experienced clinical cancer pharmacist, a consultant oncologist or haematologist and an experienced chemotherapy nurse specialist as appropriate and defined locally.


Prescribing: Security access enabling personnel to prescribe chemotherapy in line with the prescribing section of these guidelines must only be granted to locally approved prescribers. Appropriate clinical decision support and prescribing alerts (including but not limited to allergies, medication interactions, maximum or cumulative dose breaches, wrong route of administration, etc) must also be incorporated into the system.


Verification: Security access enabling personnel to verify chemotherapy medication orders on e-prescribing systems in line with the dispensing section of these guidelines must only be granted to locally approved cancer pharmacists.


Administration: Where e-prescribing systems allow electronic recording of administration, security access enabling personnel to record the administration of chemotherapy on e-prescribing systems must only be granted to approved staff who have been trained to administer chemotherapy.


Security: Levels of access must be determined locally and applied to different staff groups and/or individuals according to their professional roles and responsibilities after undertaking appropriate training (as outlined under the competency and skills sections of these guidelines related to prescribing, dispensing and administration).


Monitoring: Appropriate ongoing monitoring of e-prescribing system performance including errors and near-misses in line with the local institution’s practices must be recorded and actioned where appropriate to ensure continuous system improvement occurs and to highlight areas of risks being inadvertently introduced into practice.


System Governance and Policies: Procedures for system set-up and use, scheduled and unplanned downtime and disaster recovery must be developed and maintained.

(British Oncology Pharmacy Association, 2015)[11] ;(Australian Commission on Safety and Quality in Health Care, 2011a)[13] ;(Australian Commission on Safety and Quality in Health Care, 2011b)[15]


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References

  1. Meisenberg BR, Wright RR, Brady-Copertino CJ. Reduction in chemotherapy order errors with computerized physician order entry. J Oncol Pract 2014 Jan;10(1):e5-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24003174.
  2. McKavanagh D. A prospective audit of data quality of handwritten orders and electronically generated orders for adult chemotherapy. Asia Pac J Clin Oncol 2010;6:218.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 11.0 11.1 11.2 British Oncology Pharmacy Association (BOPA). Standards for Reducing Risks Associated with e-Prescribing Systems for Chemotherapy. [homepage on the internet]; 2015 [cited 2016 Sep]. Available from: http://www.bopawebsite.org (Members only section).
  12. Vowels M. Review of Etoposide Phosphate dosing in the Oncology Unit. [homepage on the internet] Women’s and Children’s Hospital (WCH) Children, Youth and Women’s Health Service, Adelaide, South Australia.; 2008 [cited 2016 Sep]. Available from: http://www.health.sa.gov.au/Default.aspx?tabid=52&mid=449&ctl=ViewDetails&ItemID=1820&PageIndex=0.
  13. 13.0 13.1 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.
  14. Institute for Safe Medication Practices (ISMP) and the Institute for Safe Medication Practices Canada (ISMP Canada). 2012 ISMP International Medication Safety Self Assessment® for Oncology. [homepage on the internet]; 2012 [cited 2016 Sep]. Available from: https://mssa.ismp-canada.org/oncology.
  15. 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.

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