Effects of chemotherapy prescription clinical decision-support systems on the chemotherapy process: A systematic review

Advanced prescription of injectable anticancer drugs: Safety assessment in a European Comprehensive Cancer Centre using the risk matrix approach

AIMS

The purpose of this work was to assess failures in the advanced prescription of parenteral anticancer agents in an adult day oncology care unit with more than 100 patients per day.

METHODS

An a priori descriptive analysis was carried out by using the risk matrix approach. After defining the scope in a multidisciplinary meeting, we determined at each step the failure modes (FMs), their effects (E) and their associated causes (C). A severity score (S) was assigned to all effects and a probability of occurrence (O) to all causes. These S and O indicators, were used to obtain a criticality index (CI) matrix. We assessed the risk control (RC) of each failure in order to define a residual criticality index (rCI) matrix.

RESULTS

During risk analysis, 14 FMs were detected, and 61 scenarios were identified considering all possible effects and causes. Nine situations (15%) were highlighted with the maximum CI, 18 (30%) with a medium CI, and 34 (55%) with a negligible CI. Nevertheless, among all these critical situations, only three (5%) had an rCI to process (i.e., missed dose adjustment, multiple prescriptions and abnormal biology data); the others required monitoring only. Clinicians' and pharmacists' knowledge of these critical situations enables them to manage the associated risks.

CONCLUSIONS

Advanced prescription of injectable anticancer drugs appears to be a safe practice for patients when combined with risk management. The major risks identified concerned missed dose adjustment, prescription duplication and lack of consideration for abnormal biology data.

A network pharmacology, molecular docking and in vitro investigation of Picrorhiza kurroa extract for the treatment of diabetic nephropathy

Picrorhiza kurroa Royle ex Benth. (P. kurroa/PK/Kutki), a Himalayan herb belonging to the family Scrophulariaceae, is widely known for its hepatoprotective activity. Traditionally, it is found to be effective for upper respiratory tract disorders, kidney and liver problems, dyspepsia and chronic diarrhoea but the mechanism of action is unclear. In this study, the mode of action of P. kurroa for the treatment of diabetic nephropathy (DN) was investigated by network pharmacology, molecular docking and in vitro assays. Numerous databases have been screened and 33 P. kurroa bioactive compounds and 56 targets were identified. The compounds-targets network, targets-pathways network and compounds-targets-pathways network were constructed. The major bioactive compounds include picrorhizaoside D, scrophuloside A, vanillic acid, arvenin I, cinnamic acid, picein, 6-feruloyl catalpol, picroside V, pikuroside, apocynin, picroside I, picroside IV, androsin, cucurbitacin P, boschnaloside, kutkoside, cucurbitacin O, cucurbitacin K, picracin, etc. The potential protein targets identified in this study were MMP1, PRKCA, MMP7, IL18, IL1, TNF, ACE, ASC, CASP1, NLRP3, MAP, KURROA1, mitogen-activated protein kinase (MAPK)14 and MAPK8. In the Database for annotation visualization and integrated discovery (DAVID) pathways and Gene Ontology enrichment analysis, 14 major DN signalling pathways were identified, including MAPK, renin-angiotensin system (RAS), TNF, signal transducer and activator of transcription (JAK-STAT), TLR, vascular endothelial growth factor (VEGF), mTOR, Wnt, Ras, PPARs, NFB, NOD and phosphatidylinositol signalling pathways. A molecular docking study revealed that 32 bioactive compounds of P. kurroa interacted with 14 significant proteins/genes associated with DN. P. kurroa extract was proven to enhance the survival rate of HEK cells significantly. Protein expression analysis using Western blot demonstrated that P. kurroa extract significantly altered the expression of p47phox, p67phox, gp91phox, IL-1 and TGFβ-1. As a result of network pharmacology and docking work, new concepts for discovering bioactive compounds and effective modes of action could be developed. The potential effect of P. kurroa extract on DN disease was evident in the in-vitro studies aided by network pharmacology and molecular docking.Communicated by Ramaswamy H. Sarma.

Impact of Computerized Provider Order Entry on Chemotherapy Medication Errors: A Systematic Review

Context: Chemotherapy errors are considered the second most common cause of fatal medication errors (ME). Currently, computerized provider order entry (CPOE) is increasingly used to prevent or decrease ME and improve the safety of the medication process. Objectives: This study was conducted to systematically review the impacts of CPOE on the incidence of chemotherapy ME, the severity of errors, and adverse drug events (ADEs) in cancer care units. Data Sources: The literature search was conducted, using 5 databases of PubMed, EMBASE, Scopus, Web of Science, and ScienceDirect between 2000 and 2020. Search terms included keywords and MESH terms related to CPOE, ME, chemotherapy, and cancer care unit. Study Selection: Articles were included in this research if they investigated the CPOE system, reported ME, and were carried out in the oncology department. Non-English papers, duplications, review studies, and conference papers were excluded. Data Extraction: The selected papers were read repeatedly and related papers were extracted. All eligible articles were qualitatively evaluated with a tool provided by Downs. The extracted information included the author’s name, year of publication, study location, type of study, study objectives, and main findings. Results: A total of 829 studies were retrieved. Fourteen articles met the inclusion criteria. Ten studies (71%) reported the impact of CPOE on chemotherapy ME in comparison with the paper-based ordering method. In 4 studies (29%), researchers developed a CPOE for the oncology department, and the system was, then, assessed concerning user experience, safety challenges as well as the effects of CPOE on ME. Nine articles (64%) reported the impact of the CPOE system on ME only in the prescribing phase, and 5 studies (36%) examined ME in all phases of the chemotherapy process. Five studies (36%) reported the impact of the CPOE system on ADEs and the severity of errors. Conclusions: Implementing CPOE is associated with a significant reduction in ME in all phases of the chemotherapy process. However, the CPOE does not prevent all MEs and may cause new errors. The rigorous analysis of the chemotherapy process and considering the designing principles could help develop the CPOE systems and minimize ME.

A Clinical Decision Support System for Increasing Compliance with Protocols in Chemotherapy of Children with Acute Lymphoblastic Leukemia

Objective:

In this survey, a protocol-based Chemotherapy Prescription Decision Support System (CPDSS) was designed and evaluated to reduce medication errors in the chemotherapy process of children with ALL.

Methods:

The CPDSS algorithm was extracted by the software development team based on the protocol used by doctors to treat children with ALL. The ASP.Net MVC and SQL Server 2016 programming languages were used to develop the system. A 3-step evaluation (technical, retrospective, and user satisfaction) was performed on CPDSS designed at 2 children’s hospitals in Tehran. The data were analyzed using descriptive statistics. At the technical evaluation step, users provided recommendations included in the system.

Results:

In the retrospective CPDSS evaluation step, 1281 prescribed doses of the drugs related to 30 patients were entered into the system. CPDSS detected 735 cases of protocol deviations and 57 (95%, CI = 1.25-2.55) errors in prescribed chemotherapy for children with ALL. In the user satisfaction evaluation, the users approved two dimensions of the user interface and functionality of the system.

Conclusions:

With the provision of alerts, the CPDSS can help increase compliance with chemotherapy protocols and decrease the chemotherapy prescribing errors that can improve patient safety.

Usage and Usability of a National e-Library for Chemotherapy Regimens: Mixed Methods Study

Background

Accurate information about chemotherapy drugs and regimens is needed to reduce chemotherapy errors. A national e-library, as a common knowledge source with standardized chemotherapy nomenclature and content, was developed. Since the information in the library is both complex and extensive, it is central that the users can use the resource as intended.

Objective

The aim of this study was to evaluate the usage and usability of an extensive e-library for chemotherapy regimens developed to reduce medication errors, support the health care staff in their work, and increase patient safety.

Methods

To obtain a comprehensive evaluation, a mixed methods study was performed for a broad view of the usage, including a compilation of subjective views of the users (web survey, spontaneous user feedback, and qualitative interviews), analysis of statistics from the website, and an expert evaluation of the usability of the webpage.

Results

Statistics from the website show an average of just over 2500 visits and 870 unique visitors per month. Most visits took place Mondays to Fridays, but there were 5-10 visits per day on weekends. The web survey, with 292 answers, shows that the visitors were mainly physicians and nurses. Almost 80% (224/292) of respondents searched for regimens and 90% (264/292) found what they were looking for and were satisfied with their visit. The expert evaluation shows that the e-library follows many existing design principles, thus providing some useful improvement suggestions. A total of 86 emails were received in 2020 with user feedback, most of which were from nurses. The main part (78%, 67/86) contained a question, and the rest had discovered errors mainly in some regimen. The interviews reveal that most hospitals use a computerized physician order entry system, and they use the e-library in various ways, import XML files, transfer information, or use it as a reference. One hospital without a system uses the administration schedules from the library.

Conclusions

The user evaluation indicates that the e-library is used in the intended manner and that the users can interact without problems. Users have different needs depending on their profession and their workplace, and these can be supported. The combination of methods applied ensures that the design and content comply with the users’ needs and serves as feedback for continuous design and learning. With a broad national usage, the e-library can become a source for organizational and national learning and a source for continuous improvement of cancer care in Sweden.

A Tertiary Academic Medical Center Blood Bank's Experience With Four-Factor Prothrombin Complex Concentrate

OBJECTIVES

The role of transfusion medicine consultative services in prospectively auditing (PA) orders for four-factor prothrombin complex concentrate (4F-PCC) was evaluated at an academic medical center.

METHODS

Data from 4 years of 4F-PCC orders were obtained from the laboratory information system, and electronic health records of patients receiving concentrate were reviewed.

RESULTS

4F-PCC was ordered for 427 patients with warfarin-, apixaban-, or rivaroxaban-associated hemorrhage. Turnaround time (TAT) to prepare 4F-PCC was longer when PA-recommended dose adjustments were needed (85 vs 66 minutes, P = .03). There was no difference in TAT between patients who died and those who were ultimately discharged (60 vs 70, P = .22). TAT was shortest for orders originating in the emergency department (ED) compared with other locations (64 vs 85, P < .001), and ED TAT was not associated with patient outcomes in ED patients. PA and dose adjustments reduced amounts of concentrate issued by 27 IU per dose (P = .01). Median international normalized ratio less than 1.3 after 4F-PCC transfusion was achieved for all anticoagulants after dose adjustments. PA did not affect order cancellation or product wastage rates.

CONCLUSIONS

PA can ensure 4F-PCC is dosed appropriately without affecting patient outcomes.

The effect of a Clinical Decision Support System on the frequency of dose adjustments of anticancer drugs in case of renal or hepatic dysfunction

INTRODUCTION

Dose adjustments in patients with renal or hepatic dysfunction using anticancer drugs are indicated according to guidelines. However, implementation depends on awareness of prescribing physicians. We implemented a Clinical Decision Support System (CDSS), recommending dose adjustments upon electronic prescriptions based on renal and hepatic function. The alert provides a dose adjustment proposal and recent laboratory results. Our objective was to determine the frequency of dose adjustments before and after implementation of this CDSS.

METHODS

We included all first orders for patients ≥18 years treated with parenteral antineoplastic agents, for whom dosage adjustment is necessary based on renal or hepatic function between February 2018 and January 2019. This study was performed at the department of Clinical Oncology and Hematology of the Amsterdam University Medical Center. We implemented the CDSS August first. All prescriptions were prescribed according to common practice. We analyzed the orders where a dose reduction based on renal or hepatic function was indicated.

RESULTS

We included 73 orders before implementation and 99 orders after implementation. Before implementation 21% of doses were reduced in line with the guidelines versus 34% after implementation (p = 0.048). For hepatic dysfunction the proportion changed from 11% to 46% p = 0.011, while there was no effect for renal dysfunction (24% vs. 26% p = 0.75).

CONCLUSION

Dosages are more frequently adjusted in concordance with guidelines in patients with hepatic dysfunction who are treated with parenteral antineoplastic agents after implementation of a CDSS. The change was not seen in patients with renal dysfunction.

Virtual reality teaching in chemotherapy administration: Randomised controlled trial

AIMS AND OBJECTIVES

This study examined the effect of virtual reality (VR)-based documents (VRdocs) on knowledge and attitude towards chemotherapy administration in nursing students.

BACKGROUND

Chemotherapeutic drugs in cancer patients are a complicated and dangerous process. However, despite the high toxicity of the chemotherapeutic drugs, the compulsory or internship courses in nursing schools do not include training in operational chemotherapeutics and its associated safety measures.

DESIGN

A randomised controlled trial based on the CONSORT 2010 guidelines (registry number: NCT03707210).

METHOD

A total of 77 students were randomised to an experimental (VRdocs, n = 38) or a control group (n = 39). Pre- and posttest data were collected. After the pretest, the control group received the education documents, whereas, the experimental group used VR software consisting of an application about chemotherapy administration. Finally, the effectiveness of the intervention was self-evaluated using questionnaires after 7 days.

RESULTS

The posttest scores for knowledge (F = 6.412, p = .013) and attitude in the experimental group were significantly different from those in the control group (F = 8.469, p = .005). Compared with the control group, a significant number of students in the experimental group indicated their higher recommendation score for the VRdocs (p = .0001).

CONCLUSION

Schools must provide a variety of handouts and teaching methods to educate nursing students about high-risk nursing techniques. Methods using VR can address the shortcomings of the traditional documents, and the use of both methods simultaneously can produce better learning results.

RELEVANCE TO CLINICAL PRACTICE

Virtual reality based documents were provided to the participants to understand the preparation, implementation, and safety of chemotherapy. VRdocs allow students to re-learn high-risk care techniques without the influence of time and space and may prove useful for other nursing courses.

Practice-enhancing publications about the medication-use process in 2019

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change.

SUMMARY

A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.

Chitosan microparticles as entrapment system for trans- cinnamaldehyde: Synthesis, drug loading, and in vitro cytotoxicity evaluation

The ionic gelation method was used to study the effect of the crosslinking agent, sodium tripolyphosphate on average particle size (Dp) and zeta potential (ζp) of chitosan microparticles (CSMP) unloaded and loaded with trans-cinnamaldehyde (TCIN). The obtained values of Dp and ζp trend as 117.6 ± 0.4 ≤ Dp ≤ 478.5 ± 3.5 nm and +27.8 ± 1.3 ≤ ζp ≤ +103.5 ± 4.2 mV, respectively. The entrapment efficiency of TCIN in CSMP was 9.1 ± 2.0% and 71.5 ± 2.9% was released after 360 min (pH = 6.5) which reveals a potential anti-cancer activity in acidic environment. Cytotoxicity of TCIN in DMSO (0-50 μM) was evaluated on MDCK and HeLa cell lines and exhibited low effect at either 24 or 48 h of exposure; whereas TCIN-loaded CSMP (0-50 μM) showed, after 24 h of exposure, 67.6 ± 7.0 and 64.5 ± 3.9% cytotoxicity for MDCK and HeLa cell lines, respectively. At 48 h of exposure, TCIN-loaded CSMP achieved 81.1 ± 0.26 and 77.9 ± 4.2% cytotoxicity for MDCK and HeLa cell lines, respectively.

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

BACKGROUND

There are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies.

METHODS

We conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n = 10), nurses (n = 6), a pharmacist, and oncology CPOE team members (n = 2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive).

RESULTS

Incident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and 'no go' contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients' treatments: life-long, the whole regimen, and the 'here and now'. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the 'here and now' better than a life-long or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice.

CONCLUSIONS

Within oncology, CPOE appears to move the 'mix' of risk strategies towards ultra-safe models of safety and protocol-mandated care. However, in order to operate ultra-safe strategies embedded in CPOE and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use. CPOE design can be advanced by better consideration of mechanisms to support interdependencies.

Accuracy and Effects of Clinical Decision Support Systems Integrated With BMJ Best Practice-Aided Diagnosis: Interrupted Time Series Study

BACKGROUND

Clinical decision support systems (CDSS) are an integral component of health information technologies and can assist disease interpretation, diagnosis, treatment, and prognosis. However, the utility of CDSS in the clinic remains controversial.

OBJECTIVE

The aim is to assess the effects of CDSS integrated with British Medical Journal (BMJ) Best Practice-aided diagnosis in real-world research.

METHODS

This was a retrospective, longitudinal observational study using routinely collected clinical diagnosis data from electronic medical records. A total of 34,113 hospitalized patient records were successively selected from December 2016 to February 2019 in six clinical departments. The diagnostic accuracy of the CDSS was verified before its implementation. A self-controlled comparison was then applied to detect the effects of CDSS implementation. Multivariable logistic regression and single-group interrupted time series analysis were used to explore the effects of CDSS. The sensitivity analysis was conducted using the subgroup data from January 2018 to February 2019.

RESULTS

The total accuracy rates of the recommended diagnosis from CDSS were 75.46% in the first-rank diagnosis, 83.94% in the top-2 diagnosis, and 87.53% in the top-3 diagnosis in the data before CDSS implementation. Higher consistency was observed between admission and discharge diagnoses, shorter confirmed diagnosis times, and shorter hospitalization days after the CDSS implementation (all P<.001). Multivariable logistic regression analysis showed that the consistency rates after CDSS implementation (OR 1.078, 95% CI 1.015-1.144) and the proportion of hospitalization time 7 days or less (OR 1.688, 95% CI 1.592-1.789) both increased. The interrupted time series analysis showed that the consistency rates significantly increased by 6.722% (95% CI 2.433%-11.012%, P=.002) after CDSS implementation. The proportion of hospitalization time 7 days or less significantly increased by 7.837% (95% CI 1.798%-13.876%, P=.01). Similar results were obtained in the subgroup analysis.

CONCLUSIONS

The CDSS integrated with BMJ Best Practice improved the accuracy of clinicians' diagnoses. Shorter confirmed diagnosis times and hospitalization days were also found to be associated with CDSS implementation in retrospective real-world studies. These findings highlight the utility of artificial intelligence-based CDSS to improve diagnosis efficiency, but these results require confirmation in future randomized controlled trials.

Relationship between heat treatment on structural properties and antitumor activity of the cold-water soluble polysaccharides from Grifola frondosa

Grifola frondosa is a basidiomycete fungus with potential biomedical applications owing to the presence of bioactive polysaccharides. The activities of polysaccharides are influenced by many factors, particularly temperature; however, the optimal temperature and conditions for preparation of polysaccharides from this organism have not yet been determined. Therefore, in this study, cold-water soluble polysaccharides from Grifola frondosa were extracted at 4 °C (GFP-4) and purified. GFP-4-30, GFP-4-60 and GFP-4-90 were obtained from GFP-4 after treatment at 30 °C, 60 °C, or 90 °C, respectively, for 6 h. MTT results showed that GFP-4 had the highest inhibitory effects on the proliferation of SPC-A-1 cells in vitro. High-performance gel permeation chromatography results demonstrated that the molecular weight of GFP-4 was 1.05 × 10⁶ Da and that GFP-4-30, GFP-4-60, and GFP-4-90 showed different levels of degradation and generated small molecule sugars. Fourier transform infrared spectroscopy, gas chromatography, and nuclear magnetic resonance results indicated that GFPs mainly consisted of α-D-Galp, α-D-Manp and α-D-Glcp. Periodate oxidation, Smith degradation, and methylation results showed that the backbones of the molecules consisted of 1,3-linked-Galp. After heat treatment, percentages of (1 → 3,4) α-D-Galp in heat-treated polysaccharides were obviously decreased, indicating their lower branching degree, and resulting in weaker antitumor effects. Overall, our findings demonstrated changes in the structure-activity relationships of GFP-4 after heat treatment and provided a theoretical basis for the application of GFP-4 in the food and drug industries.