June 28, 2011
Chemotherapy: The Right Dose at the Right Time to the Right Patient
Chemotherapy regimens are undoubtedly the most complicated, potentially toxic medication order-sets that there could be. Because of this, methods to prevent mistakes involve built-in redundancy by several professional disciplines. However, prevention of mistakes often fails because of a lack of recognition of errors, communication problems, and fragmentation of care. Can the electronic ordering systems of today ameliorate these failures?
Yes, and a fully integrated EHR system offers the best chance of alleviating points of error along the process of chemotherapy ordering. This doesn’t just mean making the ordering process electronic, but it requires a robust pharmacy solution, summary driven workflow drivers, EHR integration with scheduling and pharmacy and easy clinician documentation. These are all the components that have been developed in PowerChart Oncology.
I was doing a walk-through recently at a reputable academic cancer center, going through the process of chemotherapy ordering, which is currently entirely on paper. The oncology pharmacist was explaining the process of order review by pharmacy and by nursing at this institution. By professional standards, chemotherapy orders are to be reviewed by two different professionals – if possible by at least one pharmacist and one nurse. This order review is for the purpose of making sure the orders are from a protocol that is based on peer-reviewed literature and the orders reflect the appropriate doses and drugs for the particular disease state.
During the walk-through, the pharmacist showed me several examples of their chemotherapy ordering process. He told me about one of their physicians who is ‘notorious’ for ‘ordering off-protocol’. He went on to explain that there is always a good reason for going off protocol, such as the patient’s age, kidney function, or liver functions. Their process is that the pharmacist will verify the protocol modifications and make sure the changes also follow the protocol modification standards. Frequently, the pharmacist has to make adjustments to the orders according to their institutional guidelines.
This pharmacist is an oncology pharmacist, and is certified specifically in oncology pharmacy. He is the only pharmacist with such a certification in the institution. This pharmacist also works only in the oncology area, and therefore knows the physicians and patients very well. I asked about coverage when he is ill or on vacation. There is no coverage I was told, and the responsibility for these double checks falls entirely on nursing. The documentation of these safety checks is not standardized or even required, so if one of the checks does not occur, orders could potentially move through the process of getting filled anyway. Fortunately, at this institution, the nurses are also all specialized in oncology and hold oncology specific certifications. This process works for them, however, they know the process is tenuous.
As this institution is looking at implementing PowerChart Oncology, the advantages of electronic ordering of chemotherapy and order verification is obvious. Not only does the electronic system streamline the entire ordering process and remove the obvious difficulties with handwriting problems, but it also allows the system to assist the clinicians in maintaining standards and consistency across providers and settings. Pre-built electronic order-sets have been pre-approved by the institution and are evidenced-based. Reminders are built-in and the clinician’s documentation of the verification process is transparent to the entire team. If one crucial team member is not available, like in the cancer center I just described, then that clinician’s role will have to be assumed by someone else. This is okay, because in an integrated electronic system, it becomes clear to all that the work (checking of orders and doses) has been done.
It is to the credit of detail-oriented, well-trained, and committed professionals that more life-threatening errors don’t occur in the current paper ordering process for chemotherapy. The time has come to alleviate the burden on the professional and support them with the infrastructure to support an error-free process.
Amy Strauss Tranin, ARNP, MS, AOCN, is a Healthcare Executive at Cerner Corporation, where she has been since May 2009. In this position she serves as a clinical expert in oncology to Cerner clients and potential clients as well as to the Cerner sales and intellectual property teams internally. Ms. Tranin has worked in oncology nursing for more than 20 years, having experience in almost all adult subspecialties including medical, surgical, transplant, GYN and GU oncology. Most of this work has been as an advanced practice nurse.