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:
- 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.
- 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.
- 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.
- 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.
- Weingart SN, Toro J, Spencer J, Duncombe D, Gross A, Bartel S, et al. Medication errors involving oral chemotherapy. Cancer 2010 May 15;116(10):2455-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20225328.
- Markert A, Thierry V, Kleber M, Behrens M, Engelhardt M. Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment. Int J Cancer 2009 Feb 1;124(3):722-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18989899.
- National Patient Safety Agency (NPSA). A themed review of patient safety incidents involving anti-cancer medicines. 1 November 2003 – 30 June 2008. [homepage on the internet] UK: NHS; 2010 Oct Available from: http://www.nrls.npsa.nhs.uk/resources/clinical-specialty/cancer-oncology/?entryid45=75475&p=2.
- 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.
- Jaadar Y, Vidts LA, Byl B, Jancys A, Adin DE, Vandorpe A, et al. The role of the pharmacist in improving the safety of chemotherapy and treatment with monoclonal antibodies. European Journal of Oncology Pharmacy 2014;8(3):13-8.
- Cancer Institute NSW. eviQ Cancer Treatments Online. [homepage on the internet]; [cited 2016 Sep]. Available from: https://www.eviq.org.au.
- Cancer Institute NSW. eviQ Cancer Education Online. [homepage on the internet]; Available from: https://education.eviq.org.au/.
- Nursing and Midwifery Board of Australia. Professional standards. [homepage on the internet]; Available from: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx.
- Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide, Standard 4: Medication Safety. Sydney: ACSQHC; 2012 Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/10/Standard4_Oct_2012_WEB.pdf.
- 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.
- White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Qual Saf Health Care 2010 Dec;19(6):562-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20724398.
- Polovich M, Olsen M and LeFevre KB. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (Fourth Edition). Pittsburg: Oncology Nursing Society; 2014.
- British Oncology Pharmacy Association (BOPA). Standards for Pharmacy Verification of Prescriptions for Cancer Medicines. [homepage on the internet]; 2013 [cited 2016 Sep]. Available from: www.bopawebsite.org (Members only section).
- Sabesan S, Larkins S, Evans R, Varma S, Andrews A, Beuttner P, et al. Telemedicine for rural cancer care in North Queensland: bringing cancer care home. Aust J Rural Health 2012 Oct;20(5):259-64 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22998200.
- COSA Teleoncology Guidelines Working Group. Clinical practice guidelines for teleoncology. [homepage on the internet] Sydney: Cancer Council Australia; Available from: http://wiki.cancer.org.au/australia/COSA:Teleoncology.
- South Australian Cancer Clinical Network Steering Committee. Standards for Chemotherapy Services in South Australia.; 2010 [cited 2017 May] Available from: http://www.sahealth.sa.gov.au/wps/wcm/connect/89ec480045a68ae78fdeaf9f9859b7b1/Standards+for+Chemotherapy+Services+in+South+Australia+January+2011.pdf?MOD=AJPERES&CACHEID=89ec480045a68ae78fdeaf9f9859b7b1.
- Evans JM, Qiu M, MacKinnon M, Green E, Peterson K, Kaizer L. A multi-method review of home-based chemotherapy. Eur J Cancer Care (Engl) 2016 Sep;25(5):883-902 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26545409.
- Neuss MN, Polovich M, McNiff K, Esper P, Gilmore TR, LeFebvre KB, et al. 2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. J Oncol Pract 2013 Mar;9(2 Suppl):5s-13s Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23914148.
- Institute for Safe Medication Practices. ISMP Safety alert: Fluorouracil error ends tragically, but application of lessons learned will save lives. [homepage on the internet]; 2007 Sep 20 Available from: http://www.ismp.org/newsletters/acutecare/articles/20070920.asp.
- Hoyer KA. Fluorouracil. Clin J Oncol Nurs 1999 Oct;3(4):191-2 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10703328.
- Fluorouracil: dosing errors with infusion pumps. Prescrire Int 2014 Oct;23(153):242 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25969854.