Multidisciplinary optimization of oral chemotherapy delivery at the UW Carbone Cancer Center.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 58-58
Author(s):  
Daniel Mulkerin ◽  
Mary Mably ◽  
Jason Bergsbaken ◽  
Kari Schuhmacher ◽  
Chris Nemergut ◽  
...  
Keyword(s):  
Gap Analysis ◽  
Oral Chemotherapy ◽  
Multidisciplinary Optimization ◽  
Cancer Center ◽  
Safety Standards ◽  
Institutional Practice ◽  
Caregiver Education ◽  
Chemotherapy Administration ◽  
Partial Compliance ◽  
Order Sets

58 Background: Use of oral chemotherapy is expanding and offers advantages but introduces unique safety challenges. ASCO and ONS addressed these issues with inclusion of oral chemotherapy in published chemotherapy administration safety standards. Methods: The updated ASCO/ONS standards offered a framework for the University of Wisconsin Carbone Cancer Center to evaluate and improve our practice with the goal of full compliance with these standards. Gap analysis revealed noncompliance with five and partial compliance with eleven standards. We divided areas for improvement into three foci: patient education, workflow, and information technology. Multidisciplinary groups addressed each area generating twenty-five recommendations. Important changes included: defining chemotherapy, standardization of patient and caregiver education, mandated use of standardized electronic order sets incorporating safety checks, and standardizing dose modification documentation. The revised electronic process allows for prospective order review of all oral chemotherapy by pharmacists and supports automated processes for assessing adherence and toxicities utilizing a library of scripted drug specific materials. Results: Prior to implementation of new processes we estimated that only 39% of our oral chemotherapy was delivered with potential demonstrable compliance with ASCO/ONS standards. Audit of oral chemotherapy orders from February to July 2015 now shows compliance with use of electronic chemotherapy plans in 244/251 (97.5%) of cases. Prospective pharmacist order review resulted in one or more interventions in 24% of these cases.Identification of patients to receive adherence and toxicity monitoring calls is 100%. Conclusions: Closure of significant gaps between institutional practice and published standards was accomplished for our oral chemotherapy practice. Key elements of success included: multidisciplinary approach, defining chemotherapy, leveraging our electronic health record with mandated use of standardized order sets, and standardization of clinical and educational processes. We are disseminating this approach across our regional network and we believe our tools are broadly applicable.

scholarly journals Multidisciplinary Optimization of Oral Chemotherapy Delivery at the University of Wisconsin Carbone Cancer Center

2016 ◽  
Vol 12 (10) ◽  
pp. e912-e923 ◽  
Author(s):  
Daniel L. Mulkerin ◽  
Jason J. Bergsbaken ◽  
Jessica A. Fischer ◽  
Mary J. Mulkerin ◽  
Aaron M. Bohler ◽  
...  
Keyword(s):  
Gap Analysis ◽  
Oral Chemotherapy ◽  
Multidisciplinary Optimization ◽  
Cancer Center ◽  
Oncology Nursing ◽  
Safety Standards ◽  
University Of Wisconsin ◽  
Order Sets ◽  
The University ◽  
Electronic Order

Purpose: Use of oral chemotherapy is expanding and offers advantages while posing unique safety challenges. ASCO and the Oncology Nursing Society jointly published safety standards for administering chemotherapy that offer a framework for improving oral chemotherapy practice at the University of Wisconsin Carbone Cancer Center. Methods: With the goal of improving safety, quality, and uniformity within our oral chemotherapy practice, we conducted a gap analysis comparing our practice against ASCO/Oncology Nursing Society guidelines. Areas for improvement were addressed by multidisciplinary workgroups that focused on education, workflows, and information technology. Recommendations and process changes included defining chemotherapy, standardizing patient and caregiver education, mandating the use of comprehensive electronic order sets, and standardizing documentation for dose modification. Revised processes allow pharmacists to review all orders for oral chemotherapy, and they support monitoring adherence and toxicity by using a library of scripted materials. Results: Between August 2015 and January 2016, revised processes were implemented across the University of Wisconsin Carbone Cancer Center clinics. The following are key performance indicators: 92.5% of oral chemotherapy orders (n = 1,216) were initiated within comprehensive electronic order sets (N = 1,315), 89.2% compliance with informed consent was achieved, 14.7% of orders (n = 193) required an average of 4.4 minutes review time by the pharmacist, and 100% compliance with first-cycle monitoring of adherence and toxicity was achieved. Conclusion: We closed significant gaps between institutional practice and published standards for our oral chemotherapy practice and experienced steady improvement and sustainable performance in key metrics. We created an electronic definition of oral chemotherapies that allowed us to leverage our electronic health records. We believe our tools are broadly applicable.

Cetuximab use without chronic antihistamine premedication

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 13521-13521 ◽  
Author(s):  
J. Timoney ◽  
K. Y. Chung ◽  
V. Park ◽  
R. Trocola ◽  
C. Peake ◽  
...  
Keyword(s):  
Side Effects ◽  
Cancer Center ◽  
First Year ◽  
Institutional Practice ◽  
Chemotherapy Administration ◽  
Time Period ◽  
Life Threatening ◽  
Anaphylactoid Reactions ◽  
Grade 3 ◽  
Severe Grade

13521 Background: Cetuximab is a human-murine chimeric monoclonal antibody against EGFR with approximately a 3% reported incidence of severe (≥ grade 3) anaphylactoid reactions. The overwhelming majority of such reactions have been reported with the initial dose of cetuximab. Diphenhydramine (Benedryl)or a related antihistamine is often given as a premedication for cetuximab, however this may cause fatigue or other side effects. Most early clinical trials of cetuximab permitted investigator discretion in use of premedication beyond the initial cetuximab dose. Methods: We obtained an IRB waiver of authorization to review the records of patients treated with cetuximab at Memorial Sloan Kettering Cancer Center for the first year of commercial availability of cetuximb (Feb, 2004 through Feb, 2005). Computerized pharmacy records were reviewed to identify all patients who were treated with cetuximab (outside of a clinical trial) and use of premedication was then evaluated. Records of institutional adverse event reports regarding chemotherapy administration were reviewed, and, any moderate or severe/life-threatening reactions were evaluated for presence or absence of concurrent premedication. Results: As per our institutional guidelines, all patients received 50 mg of diphenhydramine prior to the initial loading dose of cetuximab, and 25 mg of diphenhydramine prior to the second dose. While there was inconsistency in terms of cessation of diphenhydramine, overall a total of 115 patients received one or more doses of cetuximab without premedication. A total of 746 doses of cetuxmab without diphenhydramine premedication were given over this time period. No severe/life-threatening reactions to cetuximab occurred during these doses given without premedication. Conclusions: Omission of diphenhydramine premedication after the initial two doses of cetuximab is our current institutional practice, and appears not to alter the safety profile of cetuximab. Considering the side effects of diphenhydramine, routine long tern use of antihistamine premedication with cetuximab administration does not appear to be warranted. [Table: see text]

Evaluation of oral chemotherapy prescribing at an outpatient oncology clinic.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 191-191
Author(s):  
George W. Carro ◽  
Bruce Brockstein ◽  
Thomas A. Hensing ◽  
Patrick Joseph Fleming ◽  
Shannon Maureen Gavin ◽  
...  
Keyword(s):  
Chart Review ◽  
Retrospective Chart Review ◽  
Electronic Medical Record System ◽  
Pharmacist Intervention ◽  
Primary Outcome Measure ◽  
Oral Chemotherapy ◽  
Secondary Outcome ◽  
Record System ◽  
Safety Standards ◽  
Chemotherapy Administration

191 Background: Oral chemotherapy’s exponentially increasing role in the treatment of malignancies continues to pose unique challenges to oncology. The American Society of Clinical Oncology (ASCO) and Oncology Nursing Society (ONS) drafted measures in the Chemotherapy Administration Safety Standards that help address some of these issues concerning oral chemotherapy. There is a lack of data describing the prescribing process for oral chemotherapy. In a retrospective chart review, prescriptions at a hospital-based outpatient oncology center were evaluated for completeness of prescribing and follow up measures. Methods: A retrospective chart review of ten oral chemotherapy medications from May 2012 to July 2012 was conducted. The primary outcome measure was compliance with ASCO and ONS Chemotherapy Administration Safety Standards. A secondary outcome was frequency of pharmacist interventions on oral chemotherapy prescriptions. Results: 412 prescriptions were evaluated. Prescriptions were graded on a scale from 1 to 8. One point was given for inclusion of each of the following: prescribing physician, patient name, drug name, dose, dosing methodology, quantity, refills, and accurate directions. Of all the prescriptions, 23% contained all aspects of a complete prescription. The most common reasons for point deductions were contradictory or unclear directions and allowing refills for oral chemotherapy which should not be refillable. Four percent of prescriptions had a documented pharmacist intervention. Conclusions: This study revealed areas for improvement in the prescribing process of oral chemotherapy. Targeting directions and refill fields within prescription templates will improve compliance with ASCO and ONS standards. This can be accomplished by implementing customized oral chemotherapy prescription templates within treatment plans in the electronic medical record system. Unlike chemotherapy administered in the clinic setting, oral chemotherapy prescriptions are not generally reviewed by oncology trained pharmacists. With the collaboration of medical and nursing staff, a new work flow was implemented which includes pharmacist review of electronic oral chemotherapy prescriptions.

scholarly journals US Cancer Center Implementation of ASCO/Oncology Nursing Society Chemotherapy Administration Safety Standards

2012 ◽  
Vol 8 (1) ◽  
pp. 7-12 ◽  
Author(s):  
Saul N. Weingart ◽  
Justin W. Li ◽  
Junya Zhu ◽  
Laurinda Morway ◽  
Sherri O. Stuver ◽  
...  
Keyword(s):  
Cancer Center ◽  
Oncology Nursing ◽  
Cancer Centers ◽  
Safety Standards ◽  
Chemotherapy Administration

Given wide variation in the implementation of ASCO/Oncology Nursing Society chemotherapy administration safety standards at US cancer centers, there are significant opportunities for improvement.

Challenges of implementing the ASCO/ONS oral chemotherapy standards in a community practice network.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 93-93
Author(s):  
Carole Kathleen Dalby ◽  
Jodi Thiele ◽  
Jeanna Hamilton Walsh ◽  
Frances Fuller ◽  
Michael Constantine ◽  
...  
Keyword(s):  
Nursing Education ◽  
Gap Analysis ◽  
High Reliability ◽  
Treatment Plan ◽  
Oral Chemotherapy ◽  
Oral Drug ◽  
Quality Improvement Initiative ◽  
Community Practice ◽  
Chemotherapy Treatment ◽  
Chemotherapy Administration

93 Background: In March 2013, The American Society of Clinical Oncologists and the Oncology Nursing Society published standards for the safe administration of oral chemotherapy. Gap analysis at Dana-Farber Cancer Institute (DFCI) Satellites revealed opportunities in planning, education, and monitoring of patients prescribed oral chemotherapy. As a quality improvement initiative, the DFCI Satellites designed and implemented a multidisciplinary approach to oral chemotherapy administration. Methods: The Model for Improvement was employed. A process map highlighted gaps in oral chemotherapy. Several improvement opportunities were identified. 1) Pharmacists developed oral chemotherapy treatment algorithms in the EMR. 2) Providers adapted the parenteral chemotherapy treatment plan (CTP) for use with oral chemotherapy. 3) A nursing education program was created, and implemented following completion of the CTP and consent. 4) Continuous monitoring for toxicity and adherence was initiated by providers via clinic visits and telephone screening. Results: Monthly compliance reports measured CTP completion, consent, initial education, and monitoring for adherence. Aggregated rates indicate practice variability. Some sites perform well, while others continue to show room for improvement. Conclusions: Developing a process for oral chemotherapy is challenging. Systems are not set up for oral drug safety. Although we had success with introduction of the intervention, results have not yet demonstrated sufficient reliability. System limitations and human factor challenges have impeded progress. Given the risk potential of oral chemotherapy, adopting a robust process to deliver oral chemotherapy is essential for safe patient care. Oral chemotherapy administration is a work in progress that must be refined to achieve high reliability. [Table: see text]

scholarly journals 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

2013 ◽  
Vol 9 (2S) ◽  
pp. 5s-13s ◽  
Author(s):  
Michael N. Neuss ◽  
Martha Polovich ◽  
Kristen McNiff ◽  
Peg Esper ◽  
Terry R. Gilmore ◽  
...  
Keyword(s):  
Clinical Oncology ◽  
Oral Chemotherapy ◽  
Parenteral Administration ◽  
Oncology Nursing ◽  
Intravenous Chemotherapy ◽  
Good Practices ◽  
Safe Delivery ◽  
Safety Standards ◽  
Chemotherapy Administration ◽  
American Society

Chemotherapy providers have generally developed and implemented good practices around the safe delivery of intravenous chemotherapy. Nonetheless, practices applying for QOPI certification usually modify or expand one or more processes to meet standards for safe parenteral administration.

Developing a standardized protocol for the prescription of oral chemotherapy.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 120-120
Author(s):  
Nirav Niranjan Shah ◽  
Donna L. Capozzi ◽  
Erica Casella ◽  
Suzanne McGettigan ◽  
Tara C. Gangadhar ◽  
...  
Keyword(s):  
Informed Consent ◽  
Policy Change ◽  
Nurse Practitioners ◽  
Oral Chemotherapy ◽  
Route Of Administration ◽  
University Of Pennsylvania ◽  
Cancer Center ◽  
Safety Standards ◽  
Time Period ◽  
The University

120 Background: Over the last 10 years there has been a dramatic increase in the use of oral chemotherapy in the treatment of cancer. However, despite the route of administration, oral chemotherapies carry many of the same risks as intravenous agents and may have greater risks of drug-drug interactions due to variability in absorption and metabolism. Due to these risks, ASCO included oral chemotherapy as part of their updated chemotherapy safety standards in 2013. With this in mind, we sought to examine and improve the reliability and safety of the oral chemotherapy prescription process at the Abramson Cancer Center (ACC) of the University of Pennsylvania. Methods: A multi-disciplinary quality improvement team consisting of oncologists, nurse practitioners, and pharmacists was formed to analyze the current state of our oral chemotherapy practice. We identified an absence of signed informed consent and lack of pharmacist prescription review as areas for improvement. To address these deficiencies, we electronically routed our oral chemotherapy orders to an oncology specific pharmacist for review and implemented a policy change requiring that oral chemotherapy have signed informed consent. These changes were applied to the melanoma group of the ACC. Results: Over a 3 month time period, 33 orders for oral chemotherapy were placed for 18 individual patients. Signed informed consent was obtained in 9 of 18 patients (50%). Of the 33 orders, all were reviewed by ACC pharmacists, and as a result, 11 interventions were made by these providers (33%). Types of interventions included dose adjustment (9%), modification of an interacting drug (27%), and additional monitoring specific to the oral agent (64%). Conclusions: Despite its route of administration, oral chemotherapy should be prescribed and reviewed with the same oversight as intravenous chemotherapy. At our institution, involvement of an oncology specific pharmacist in the review of oral chemotherapy led to meaningful interventions in about 1/3 of orders, and with a policy change, signed informed consent was performed in 1/2 of patients. Given these findings, and the clinical implications of this pilot, we plan to continue to study and disseminate this intervention throughout our cancer center.

Chemotherapy safety initiative.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 226-226
Author(s):  
Maria Tomaro ◽  
Paula Silverman ◽  
Wendy Rowehl Miano ◽  
Amy Wakeling ◽  
Kathleen Gonzalez
Keyword(s):  
Medication Errors ◽  
Gap Analysis ◽  
Safety Margin ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Institute Of Medicine ◽  
University Hospitals ◽  
Minor Variation ◽  
Order Sets ◽  
Order Set

226 Background: The 2006 Institute of Medicine report "Preventing Medication Errors," stated that “medication errors harm at least 1.5 million patients every year…” Chemotherapy (CT) has a narrow therapeutic index and safety margin which can and does lead to fatal errors. University Hospitals Seidman Cancer Center (UHSCC), an National Cancer Institute (NCI) designated Comprehensive Cancer Center, dispensed 10,500 CT doses in 2012 and has taken an active approach to enhance CT safety. Methods: In the last quarter of 2012, a nurse coordinator (NC) for chemotherapy orders and a Chemotherapy Safety Governance Committee (CSGC) was conceptualized. The NC’s role would be to incorporate CT safety best practices into order set development. The charter for the CSGC includes 1) to establish cancer CT standards and operating procedures across the adult and pediatric oncology population; 2) to develop and oversee cancer CT order set infrastructure applicable to our hybrid electronic/paper current state; and 3) to lead performance improvement initiatives related to CT safety. Leading organizations involved in oncology practice and medication safety standard-setting (ASCO, Oncology Nursing Society, Institute For Safe Medication Practices, National Comprehensive Cancer Network, Journal of Cancer Research) were reviewed for recommendations for standards for CT order sets. Results: Thirty standards for a CT order template were identified by the NC. A comprehensive gap analysis was completed to compare the current inpatient and ambulatory CT order sets to these standards. Results of the gap analysis were brought to the CSGC, a multi-disciplinary group of cancer and quality clinicians and leaders over 6 meetings. Consensus was achieved on the application of these standards to CT order sets. Our new orders will adopt 100% of all identified standards for CT orders. Conclusions: The gap analysis led to the development of a CT order set template that maximizes safety by applying best-practice standards. This template is designed to be applicable to electronic and paper-based order sets and with minor variation, appropriate to all disease-based order sets. This template is currently being utilized to revise 330 electronic and 398 paper CT order sets at UHSCC. [Table: see text]

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