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.
The risks associated with incorrect administration of systemic cancer therapies are well described in the literature. 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.
The 'Time Out' procedure should be used when administering cancer therapy and enables a final safety check. eviQ Cancer Education Online provides useful detail on the ‘Safe Administration of Antineoplastic Drugs’ and the ‘Time Out’ procedure’.
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.
The following recommendations are made in addition to local, state and commonwealth legislative requirements.
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):
The following should be checked to successfully verify the cancer therapy against the medication order (Cancer Institute NSW, 2016):
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) ;(Goldspiel et al, 2015) ;(Neuss et al, 2017) ;(White et al, 2010) ;(Polovich et al, 2014) ;(British Oncology Pharmacy Association, 2013) ;(Cancer Institute NSW, 2016)
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
|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)
| 2. Prescription/medication order
| 3. Protocol and scheduling
| 4. Prescribed medication, dose calculations
| 5. Patient organ function and laboratory blood tests
|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:
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