Faculty Disclosures Electronic Prescribing of Chemotherapy-It s Not a Video Game! Mary Mably has no disclosures Mary S. Mably, RPh, BCOP Pharmacy Oncology Coordinator, University of Wisconsin Hospital and Clinics Heimberg J, et al. N Engl J Med. 1999;102:365-78 Objectives Define the source(s) of the new errors seen with this method of prescribing Identify the unique errors found with electronic prescribing of Recommend practices that improve safety in the electronic prescribing of Chemotherapy Errors Range from incomplete orders to life-threatening errors Information on the frequency of errors is scarce and varies from 3% to 19% Electronic prescribing of can yield significant benefits in safety, although there have been errors attributed to the implementation and use of this Mertens, W, et al. Jt Comm J Qual Patient Saf. 2012;38(11):497-505. Which of the following is a common source of errors seen with electronic (computerized) prescribing of? Why Use Electronic Prescribing? 1. Standardized supportive care 2. Electronic decision support 3. Bypassing built-in safeguards 4. Calculation of doses 5. Less complete orders than paper orders Benefits Standardization of protocol prescribing and standards of care Legibility Automatic dose calculation Electronic decision support More complete than paper ordering Accessible from other locations Barriers Prescriber buy-in and work arounds Modifications to reviewed builds compromise patient safety False sense of security with pre-made builds Video game prescribing Sklarin N, et al. J Oncol Pract. 2011;7(4):213-8.
Standard or Specific? Standard Across Plans Treatment plan summary Drug Dose Days of therapy Cycle, course length References Consent Follow-up Specific to Plan Pre-treatment Labs Hold parameters: (examples- ANC, platelet count, urine protein) Patient instructions Supportive care Prescriptions (orders) Sources of Errors Incorrect data entry Error in electronic build System designs poor data organization data omissions Workflows outside of the electronic build Confusing treatment plan option presentation may result in choice of incorrect treatment plan Campbell EM, et al. J Am Med Inform Assoc. 2006 Sep-Oct; 13(5):547-56. Jacobson, JO, et al. JCO 2009 Nov10;27(32):5469-75 Prescriber Issues New practitioners/trainees may not learn how to write orders due to an overdependence on technology Training process Quality assurance Tendency to view as task to complete, rather than as a tool to safely prescribe Copy/paste issues within treatment plan Pharmacy Issues Workflows that occur outside of electronic prescribing Manipulation of high-risk medication Electronic build of medications Dosing units Route(s) of administration Dose rounding Dose caps Administration instructions Drug Interactions Campbell, E, et al. AMIA Annu Symp Proc. 2007 Oct11:94-8 Oral Chemotherapy Implementation of electronic prescribing systems has demonstrated a significant reduction in prescribing errors with oral Unique challenges May be filled at a pharmacy with no knowledge of patient/diagnosis/laboratory values/ regimen Difficult to enforce use of care plans, rather than writing a prescription Chemotherapy Drug Shortages Challenge to maintain electronic records in era of multiple, changing shortages Possibility of errors with incorrect medication record different concentration different dilution or administration instructions Collins CM, et al. Int J Qual Health Care. 2011 Feb;23(1):36-43
Which of the following represents an unique error that may be found with electronic prescribing with that was NOT found when using paper orders? 1. Patient has an allergy to ondansetron, yet was prescribed ondansetron. 2. Physician has propagated a dose change based on a changing lab value to all future cycles. 3. Sufficient antiemetics for home use were not prescribed. 4. Dose of doxorubicin was miscalculated. 5. Pre-hydration was not prescribed for use with high dose cyclophosphamide. Opportunities to Improve Patient Care Quality improvement within medical oncology Safe administration of Treatment plan summary as source of truth Multidisciplinary review Standardization of prescribing Standardization of supportive care Standardization of administration Treatment plan notes Brockstein, B, et al. J Oncol Pract. 2011;7(4):e20-4. Quality Improvement Treatment plan summary Opportunity for oncology pharmacists to take leadership role using information from the electronic health record Made possible by electronic health record Made feasible by electronic health record Brockstein, B, et al. J Oncol Pract. 2011;7(4):e20-4. Multidisciplinary Review Committee based review by health care workers with different perspectives physician nurse pharmacist Standardization If you think of standardization as the best that you know today, but which is to be improved tomorrow; you get somewhere. Henry Ford A framework of agreements to which all relevant parties in an industry or organization must adhere to ensure that all processes associated with the creation of a good or performance of a service are performed with set guidelines. Investopedia
Standardization Opportunity to improve safety through standardization of various ordering processes Paper order sets also provided standardization of processes, but were difficult to update and maintain Standardization What can be standardized to improve safety? generic drug names only weight change alert tallman lettering for drug names ability to cap doses for specific restrict routes of administration supportive care medications and needed hydration administration of drugs take-home medications needed for regimen Sklarin N, et al. J Oncol Pract. 2011;7(4):213-8 Communication in Electronic Prescribing Modifications to treatment plans should be clearly documented dose decrease delete drug increase cycle length Treatment tolerance can be documented within treatment plans increasing patient safety Treatment Plan Notes Pharmacist enters note into electronic medical record documenting review of care plan, including lab values, dosing, supportive care, lifetime dose of anthracyclines, and modifications to the plan Education Back to basics Prescribers in training may write orders before using electronic care plan Repetitive education on the safe use of electronic tools Use of actual errors (near misses and actual errors) to educate Annual reviews for pharmacists, physicians, nurses Which of the following would improve the safety of an electronic prescribing system for? 1. Prescribers must always document the reason for dose modifications within the electronic care plan using a note 2. Allow either generic or trade names of drugs 3. Education on use of the system should consist of initial orientation and then rely on continuing use 4. Allow various antiemetic regimens for the same drug 5. Have only oncology physicians review and approve treatment plan build
Electronic Prescribing of Chemotherapy Although electronic prescribing of offers many safety advantages, there are also new and unique safety risks Healthcare providers can be lulled into a false sense of security that all errors will be caught by the electronic system Careful and thoughtful review of prescribing (paper or electronic) is necessary to protect and optimally treat our cancer patients Questions? Mary Mably, RPh, BCOP University of Wisconsin Hospital and Clinics 608-263-1263 mmably@uwhealth.org