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. 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.
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. 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. 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), the British Oncology Pharmacy Association (BOPA) Standards for Reducing Risks Associated with e-Prescribing Systems for Chemotherapy, 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).
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.
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.
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.
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