What is the procedure for the Nurse when verifying cancer therapy and related medication prior to administration?

From Cancer Guidelines Wiki

Introduction

Clinical verification of the cancer therapy order by the nurse prior to administration provides assurance that the prescribed treatment is accurate, reflective of the planned treatment and appropriate for the patient. A systematic check of each medication to be administered against the medication order is essential to ensure that the correct dose and formulation of the medication is delivered to the correct patient by the correct route at the correct time.

A process driven approach to verification of cancer therapy is essential to minimise medication errors and optimise safety in the process of providing cancer therapy.[1][2][3]


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Evidence Summary

The risks associated with incorrect administration of systemic cancer therapies are well described in the literature.[3][4][5][6][7][8] Verification of the order and medication by the nurse prior to administration to the patient provides the final check that the prescribed treatment is accurate and is consistent with the intended treatment.[2][9]

The 'Time Out' procedure should be used when administering cancer therapy and enables a final safety check.[10] eviQ Cancer Education Online provides useful detail on the ‘Safe Administration of Antineoplastic Drugs’ and the ‘Time Out’ procedure’.[11]

Fatal outcomes have resulted when calculation errors have occurred on settings (e.g. 4 days of high-dose fluorouracil in one infusion bag was inadvertently administered over 4 hours due to a mis-interpretation and mis-programing of an infusion pump). Structured processes for conducting and documenting independent double-checks for infusion pump settings are critical in minimising this type of error.


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Recommendations

The following recommendations are made in addition to local, state and commonwealth legislative requirements.[12]


Consensus-based recommendationQuestion mark transparent.png

The verification process must be documented in an up-to-date local procedure which outlines the individual systematic checks that nurses are required to undertake when verifying cancer medication orders and the medication prior to administration.


The checking process must not occur until the pharmacist’s verification process has been completed. The checking process must include a verification of the medication order AND a check that the medication to be administered is that prescribed on the order and intended to be administered by the prescriber (Australian Commission on Safety and Quality in Health Care, 2012).


The medication order and chemotherapy, targeted therapy and related medications must be checked at the point of administration by two registered nurses with the appropriate training and skills (Goldspiel et al, 2015; Neuss et al, 2017; White et al, 2010). The checking process by the two nurses should occur independently. Where a second nurse is not available then a pharmacist or a medical practitioner with appropriate knowledge and skills should perform the check. The use of systematic checklists is helpful in preventing errors (White et al, 2010; Goldspiel et al, 2015).


All dosage and administration rate-related calculations should be independently verified (Polovich et al, 2014; Neuss et al, 2017). While computerised systems may incorporate medication order safety checks, this does not negate the need for independent manual double checks (Goldspiel et al, 2015).


The five “P”s should be followed to successfully verify a cancer therapy medication order (British Oncology Pharmacy Association, 2013):

  1. Patient details and dosing variables
  2. Prescription/medication order
  3. Protocol and scheduling
  4. Prescribed medication, dose calculations and administration
  5. Patient organ function and laboratory blood tests

The following should be checked to successfully verify the cancer therapy against the medication order (Cancer Institute NSW, 2016):

  1. Correct patient
  2. Correct drug
  3. Correct dose
  4. Correct route
  5. Correct time

At the point of administration, the nurse or practitioner administering the chemotherapy must document that the previous checking process has been completed. At least two individuals in the presence of the patient must verify the identity of the patient using at least three approved patient identifiers; e.g. patient name (family and given names), date of birth, address, medical record number or individual healthcare identifier (Australian Commission on Safety and Quality in Health Care, 2012).


The performance of the above checks must be verified by signing and dating the chemotherapy medication order by both persons (either manually or electronically). This documentation should be in a standardised format.


The patient or carer should have an opportunity to check the medication against information provided and to ask questions about the treatment (Goldspiel et al, 2015). Information must be verified and checked against the medication order and the medication as detailed in Table 14 and Table 15 (White et al, 2010; Neuss et al, 2017; Goldspiel et al, 2015).

(Australian Commission on Safety and Quality in Health Care, 2012)[13] ;(Goldspiel et al, 2015)[14] ;(Neuss et al, 2017)[1] ;(White et al, 2010)[15] ;(Polovich et al, 2014)[16] ;(British Oncology Pharmacy Association, 2013)[17] ;(Cancer Institute NSW, 2016)[10]


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Patients and caregivers can play a valuable role in error prevention in the administration checking process. Explaining the checking process and what is being administered while encouraging patients to let nursing staff know if they observe anything different from the routine administration process can help identify potential errors. This needs to be balanced by the patient’s willingness and capability to support this role and provide input (Schwappach and Wernli, 2010).


Additional considerations for home administration

  • Administration of cancer treatments closer to home for people with cancer from rural and remote locations is currently being implemented in some Australian states, with verification processes supported through remote telehealth supervision (Sabesan et al, 2012; Clinical Oncology Society of Australia, 2015; SA Cancer Clinical Network Steering Committee, 2010). The governance and safety of this process must be carefully considered before implementation and balanced against the risk and benefits to the patient.
  • Administration of parenteral therapy in a patient’s home is increasingly becoming a service option in some states. Nursing staff involved in the administration of cancer therapy in the home should ensure that procedures for administration are followed that maximise patient safety and minimise the risk of errors (Evans et al, 2016).
  • Administration and checking processes may need adaptation in both these circumstances to support safe, local provision of care. It is beyond the scope of these guidelines to address the process changes that may be needed to provide these services and to address specific requirements that may apply to parenteral or oral cancer therapy administered by nursing staff in the home.

(Schwappach and Wernli, 2010)[4] ;(Sabesan et al, 2012)[18] ;(Clinical Oncology Society of Australia, 2015)[19] ;(SA Cancer Clinical Network Steering Committee, 2010)[20] ;(Evans et al, 2016)[21]


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Tables

Table 14: Cancer therapy order details to be verified by two nursing staff [2][14]

Ensure that the medication order has been verified and signed by a cancer competent pharmacist as follows:
1. Patient details, patient parameters and body surface area (BSA)

Check points:

  • The patient's name (family and given names), date of birth, gender, address and medical record number is recorded on the medication chart.
  • Adverse reactions/allergies are documented on the order or if none reported then ‘nil known allergies’ is recorded.
  • Patient dosing variables as appropriate for the required dosing calculation are recorded (height, weight, body surface area).
  • Frequency of monitoring and checking of patient’s height and weight are followed according to protocol and/or local guidelines.
  • For paediatric patients, ensure height and weight used for any dose calculations is current for that cycle and/or day of treatment.
  • The BSA is correctly calculated according to the locally agreed BSA formula (e.g. Dubois & Dubois, Mosteller).
  • A current patient treatment plan is documented and available.
2. Prescription/medication order

Check points:

  • The medication order is clear, legible and unambiguous and includes all other details as outlined in the prescribing section of these guidelines.
  • All cancer therapy medications to be administered by all routes have been prescribed as listed in the protocol.
  • If an electronic prescribing system is used to produce a paper chemotherapy prescription:
    • The printed order must be verified against the electronic copy to ensure no difference between electronic and printed order.
    • The printed copy must be verified as the most current copy that matches the electronic order with respect to the date and time the treatment was ordered and printed.
3. Protocol and scheduling

Check points:

  • The protocol name and treatment arm (where relevant) is clearly documented on the order and the protocol has been validated and approved through local approval processes.
  • The patient’s prescribed treatment reflects the treatment documented in the current plan.
  • Variations from the original protocol are intended by the prescriber, valid for the patient and protocol, and are documented with clinical justification.
  • The therapy and regimen has been prescribed according to the protocol definitions of cycle length and frequency: i.e. the length of course, time interval between each cycle is appropriate for the protocol and tumour type, and the appropriate time has passed between last cycle and current cycle.[13]
4. Prescribed medication, dose calculations

Check points:

  • All known previous adverse reactions to medications and allergies are documented and the patient has no known or documented allergies/hypersensitivity reactions to any of the medications prescribed.
  • All cancer therapy and supportive care medications prescribed are appropriate for the patient's regimen and there are no unintended omissions.
  • All doses and dose units are correct according to the protocol medication within the regimen.
    • All doses required to be calculated on a patient parameter have been calculated correctly according to patient weight, BSA, age and/or creatinine clearance.
    • Any dose reductions are correct according to the protocol, patient parameters and doctor’s instructions.
  • The administration route for each medication is correct according to the protocol and appropriate for the patient and medication prescribed and is clearly specified on the order.
  • The rate of administration (bolus, rate, length of infusion) is correctly specified.
  • Infusion solutions are compatible with other medications ordered and are appropriate for the patient's access device.
  • The volume of administration is appropriate for the size and fluid requirements of the patient.
5. Patient organ function and laboratory blood tests

Check points:

  • The absolute neutrophil count and platelet count is appropriate for administration of the chemotherapy.
  • The renal and hepatic function based on recent blood results is appropriate for all cancer and supportive medication doses.
  • All other organ function parameters and blood results including electrolytes, cardiac and respiratory function tests are within normal or protocol specified limits.


Table 15: Medication details to be verified by the nurse prior to administration [14][22][16]

Nurse/practitioner to confirm and document that the medication order verification process has been completed.
Two independent nurses to check the medication being administered for accuracy as follows:
  • Three approved patient identifiers; e.g. patient's name (family and given names), date of birth, gender, address and medical record number. This must be verified in the presence of the patient (or carer where the patient is unable to confirm).
  • The name of the medication.
  • The dose and dose unit of the medication.
  • The volume of the medication (if appropriate).
  • The route of administration.
  • The date and time of administration.
  • The rate of administration.
  • Where appropriate, infusions should be administered using infusion pumps, and preferably ‘smart pumps’. A double check of the infusion time on the pump must be confirmed.[14][15][23][24]
  • The expiry date and expiry time (where applicable) of all medication to be administered.
    • A check should be performed to ensure the product has been stored in the appropriate conditions (e.g. fridge) prior to administration. Pharmacist advice should be sought to clarify if product integrity is intact if storage conditions have been breached.
    • Preparations for parenteral administration must be checked for leaks, precipitation or any other visual signs of problems with the solution. Seek advice from the providing Pharmacist if any concerns or if advice is required.
  • Patient medication allergies and history of any hypersensitivity reactions.
  • Rate set on infusion pump (when used).[23][25]


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References

  1. 1.0 1.1 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.
  2. 2.0 2.1 2.2 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.
  3. 3.0 3.1 Mort D, Lansdown M, Smith N, Protopapa K, Mason M. For better, for worse? A review of the care of patients who died within 30 days of receiving systemic anti-cancer therapy. London: National Confidential Enquiry into Patient Outcome and Death; 2008 Available from: http://www.ncepod.org.uk/2008report3/Downloads/SACT_report.pdf.
  4. 4.0 4.1 Schwappach DL, Wernli M. Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature. Eur J Cancer Care (Engl) 2010 May;19(3):285-92 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19708929.
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