ChemoCareThe first full year
16th March 2010
1pm - 2pm
Steve EvansGail Povey
With support from: Emma Hall
Purpose of session
• Update on where we are• Pharmacy errors audits• Data quality work• Pharmacy interventions audit• Findings
• Future plans
Where are we now?
• All tumour sites
• 85% of all haematology
• Over 500 users
• Wide variety disciplines
• Canisc interface
Good time for a review of the system
Bronglais Hospital, Aberystwyth
Withybush Hospital, Haverfordwest
West Wales General Hospital, Carmarthen
Prince Philip Hospital, Llanelli
Singleton Hospital, Swansea
Morriston Hospital, Swansea
Neath Port Talbot Hospital, Neath Princess of Wales
Hospital, Bridgend
Now a Service and not a Project ....
Pharmacy errors audit findings
Percentage of prescriptions with deviations• ChemoCare introduced Sep 08• Paper system running alongside electronic• All oncology regimens live in Jan/Feb 09
More Pharmacy findings cont...
Percentage of deviations by type• Same intervention recording system used as for paper
system• Worrying rise in clinically significant errors
• Yet pharmacy felt the system safer than paper?
Antiemetic intervention
Clinically SignificantChemoCare
live
All oncology live
Data Quality – Treatment Notes
Reviewed the records of all patients in the Chemolist between 5th and 9th October 2009 (153 in total).
Checked the following key data points:• Original intent specified in notes – 75.8%• Changes to treatment specified in notes – 96.7%• Clinic letters pasted into notes – 77.1%• Nursing advice recorded as given at the first course –
42.1% *
* (excluded 8 patients who had their 1st course on paper)
Data Quality – Chemolist
Due to multiple visits the same 153 patients produced 187 attendances.
Checked that at each attendance the following was recorded on the Chemolist:• Clinical check completed – 93.6% *
• Drugs dispensed – 77.9% • Drugs given – 89.9%
* (compared with 53% in the NCEPOD report, future system fix to apply checks to all days of script will increase this figure further)
Allocation & Confirmation
As 3 patients were on 2 protocols at the same time there were 156 separate prescriptions during the audit.
The dates of allocation & confirmation were checked and those done on the same day as treatment were identified:• Allocated on day –2.6% (4) • Confirmed on day – 20.5% (32)*
* Figure drops to 27 (17.3%) if Carboplatin prescriptions are excluded.
Pharmacy interventions audit
Prospective audit• Period from February to April initially• Continue indefinitely
Joint review of processes• Not reflective of electronic system• Avoid misrepresenting the standard of prescribing
Criteria for capture taken from old and new• Broken down where too specific for either paper or
electronic
Pharmacy interventions audit cont ...
Breakdown of interventionsProcess review - issues within the processes around chemotherapy prescribing that may impact on the processing of the prescription.
Minor - defined as interventions made in response to issues that are not deemed to pose a risk of significant harm to the patient.
Major - defined as interventions made in response to issues that are deemed to probably cause significant harm to the patient if not picked up by PTS staff.
Pharmacy interventions audit cont ...
Process issuesReason Description ExampleNot recording the drugs given*
Following treatment on the system, there is a requirement to record the drugs as given via an additional screen
Drugs from previous treatment not showing as given in prescription
Deferring interventions*
These relate to users of the system deferring treatment incorrectly but do not pose a risk to the patient, i.e. chemotherapy is late on system
Patient arrives for treatment on the correct date but treatment has been deferred too far into the future. Patient has been reviewed and due to continue but the next courses have not yet been prescribed
Pharmacy interventions audit cont ...
Minor interventionsReason Description ExampleInsufficient or no intent present
There is no clear intent in the patient record
Intent form missing or not signed.Intent not clearly defined with planned protocol, number of cycles and any other treatments/ tests
No note referring to dose modification*
A dose modification is applied without adequate explanation
Reason code of ‘ENTRY ERROR’ inappropriately used or complex cases without treatment notes to clarify
Pharmacy interventions audit cont ...
Minor interventionsReason Description ExamplePatient not reviewed
Patients should be reviewed at regular intervals
Reviews should be documented in the treatment notes.
Presence of clinic letter
Antiemetic prescribing intervention
Applying the antiemetic policy incorrectly
Wrong drug or dose prescribed without reason
Incorrect drug note*
When drugs are substituted in the system, there is a requirement to amend the administration note too
Oral drugs substituted for IV but IV drug notes still appear on prescription or vice versa
Pharmacy interventions audit cont ...
Major interventions
Reason Description ExampleIncorrect dose prescribed
Incorrect dose on prescription Modification of drug applied to one cycle but not applied to remainder of cycles.Doses calculated with old GFR.
Renal function dose adjustment required following blood results.
Dose cap overridden without reason stated
Wrong treatment Treatment ordered differs from the intent
Incorrect treatment selected and differs from intent.
Includes circumstances where the individual drugs/doses may be correct, e.g. adjuvant vs advanced Trastuzumab, but may have an impact at a later date (wrong number of courses)
Pharmacy interventions audit cont ...
Major interventions
Reason Description ExampleSupportive care issue
Supportive care missing/incorrect which may cause significant harm to the patient
Essential care missing such as; antibiotic/GCSF prophylaxis, Allopurinol, Folic Acid
Does not include ‘minor’ issues such as antiemetic changes, E45 cream
Treatment interval incorrect
Treatment planned incorrectly according to protocol and poses a significant risk to the patient
Treatment not deferred correctly when patient delayed; resulting in treatment planned for 14 not 21 days.
Treatment for day 1 not deferred so that day 8 is on the system but patient is due a delayed day 1
Pharmacy interventions audit cont ...
Interventions form
Pharmacy encouraged to consider completing an incident/audit form
Pharmacy interventions audit cont ...
Findings of the audit for February
Week 1 138 14 12 10
Week 2 128 13 5 13
Week 3 165 13 16 16
Week 4 145 14 11 4
Prescriptio
n
numbersProce
ss
Issues Minor
Errors Significa
nt
Errors
Pharmacy interventions audit cont ...
Not recording drugs given 9 9 13 13
Deferring errors 5 4 1 0
Insufficient or no intent 2 1 2 1
No reason for dose modification
0 1 0 1
No MUGA result 2 0 2 3
No dose present 6 0 5 3
Incorrect dose present 4 8 10 3
Patient not reviewed 1 2 6 2
Antiemetic error 1 1 1 0
Supportive care issue 1 2 4 0
Incorrect drug note 0 0 0 0
Wrong treatment 1 2 1 0
Treatment scheduled incorrectly
4 1 1 0
Week 1
Week 2
Week 3
Week 4
2 others – EDTA requested but not used and old weight used for GFR – 1 significant , 1 minor.
Pharmacy interventions audit cont ...
Results for February 2010
Week 1 138 10.1% 8.7% 7.3% 15.9%
Week 2 128 10.1% 3.9% 10.1% 14%
Week 3 165 7.9% 9.7% 9.7% 13.4%
Week 4 145 9.7% 7.6% 2.6% 10.3%
Overall 576 9.4% 7.6% 7.5% 15.1%
Prescriptio
n
numbersProce
ss
Issues Minor
Errors Significa
nt
Errors
Total
Pharmacy interventions audit cont ...
Interesting findings Errors on a Monday are generally higher• Confirmations being done on the day
• 76% confirmed on the Monday not Friday• showed 52% error rate (13/25)
Pharmacy interventions audit cont ...
Interesting findings cont .... Use of entry error
Consultant 1 18.5%
Consultant 2 9%
Consultant 3 5%
Consultant 4 17%
Consultant 5 18%
Consultant 6 31%
Consultant 7 9%
Consultant 8 25%
Consultant 9 20%
Consultant 10 19%
Some numbers are strangely high•Training issues?•More reason codes required?
Pharmacy interventions audit cont ...
We accept the system is not perfect• There is a recognised flaw in deferring
• To be fixed in next release
• Carbo dosing is not straight forward• Access to patient record is long winded for
from nursing perspective• Will improve in next release
• One size does not fit allWith constant monitoring and feedback results can be improved
Pharmacy interventions audit cont ...
Previous levels of interventions at around 25 - 30% +Currently at 10 - 15%• Easier to find issues
• All relevant information in one place• More stringent recording of issues
• More clearly defined• Recording a wider range of interventions
Scope for this to reduce further
Future plans
ChemoCare version 5.2 in to Test environment on 22nd March. This includes:
• ChemoSchedule• Diary and Chair management system• Big task that will be done at smaller unit first
• Security matrix• Allow mapping of roles with tasks
ie. Registrars deleting future treatments
• Pharmacy module• Standardising worksheets and labels• Enhanced module is possibility
Questions ?????
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