The impact of computerized prescribing on error rate in a department of Oncology/Hematology

Evaluation of clinical decision support systems in oncology: An updated systematic review

With increasing reliance on technology in oncology, the impact of digital clinical decision support (CDS) tools needs to be examined. A systematic review update was conducted and peer-reviewed literature from 2016 to 2022 were included if CDS tools were used for live decision making and comparatively assessed quantitative outcomes. 3369 studies were screened and 19 were included in this updated review. Combined with a previous review of 24 studies, a total of 43 studies were analyzed. Improvements in outcomes were observed in 42 studies, and 34 of these were of statistical significance. Computerized physician order entry and clinical practice guideline systems comprise the greatest number of evaluated CDS tools (13 and 10 respectively), followed by those that utilize patient-reported outcomes (8), clinical pathway systems (8) and prescriber alerts for best-practice advisories (4). Our review indicates that CDS can improve guideline adherence, patient-centered care, and care delivery processes in oncology.

Transition to ePrescribing for systemic anti-cancer therapy - Perceptions of a multidisciplinary haematology/oncology team in a large teaching hospital

INTRODUCTION

A National Cancer Information System is planned for phased implementation in Irish cancer centres to enable electronic prescribing (ePrescribing) of systemic anti-cancer therapy. This study aimed to capture the opinions of healthcare professionals in a hospital setting relating to the current paper-based workflow for systemic anti-cancer therapy prescribing and their attitudes and expectations of the new ePrescribing system to develop recommendations, which assist in the planning and implementation of future ePrescribing systems.

METHODS

A mixed methods study of concurrent design was conducted. Interviews with healthcare professionals primarily aimed to evaluate processes and identify areas requiring improvement within the current paper-based workflow for systemic anti-cancer therapy prescribing. An online questionnaire adapted from the Information Systems Expectations and Experiences tool primarily aimed to capture expectations of the new ePrescribing system and attitudes towards the transition.

RESULTS

Twelve healthcare professionals were interviewed, and 50 healthcare professionals responded to the online questionnaire (response rate: 33.3%). Eight major themes emerged from interview transcripts relating to opinions on the paper-based workflow. Questionnaire respondents reported positive attitudes towards ePrescribing implementation and had high expectations for workflow improvements and functionalities of the new system. Seven recommendations for ePrescribing implementation were developed: (1) prioritise specific processes; (2) plan for changes in communication; (3) repeat research in the post-implementation setting; (4) ensure good information technology infrastructure and system support; (5) ensure optimum training; (6) outline limitations of clinical decision support; (7) provide clear instructions on local configurability.

CONCLUSION

This study identifies potential challenges in transitioning to ePrescribing and provides recommendations, which assist stakeholders in ensuring safe and effective transitions, thus informing future ePrescribing systems' implementation in haematology/oncology settings.

Medication errors in cancer therapy: Reports from German hospital pharmacists between 2008 and 2019

OBJECTIVE

Since medication errors can have severe consequences, the development of methods to improve patient safety is becoming increasingly important. The aim of this evaluation was to identify frequent medication errors in oncology as well as characteristic correlations in the various error patterns. In addition, the implementation rate of the proposed pharmaceutical intervention was determined in order to assess the benefit of a clinical pharmacist in the field of oncology.

METHODS

The evaluation was based on a data-set from a national documentation system for medication errors and interventions (DokuPIK) used by hospital pharmacists in the field of oncology from 2008 to 2019, namely 6684 reported cases in oncology, representing about 5% of all reports in DokuPIK.

RESULTS

The most frequently reported errors were incorrect doses (22% of reported errors), followed by interactions (14%); in 10% of errors the prescription/documentation was incomplete/incorrect. The intervention suggested by the pharmacist was implemented in 97% of the cases. Based on the respective Anatomical Therapeutical Chemical Classification (ATC codes), drugs (or groups of drugs) were identified that were reported frequently in connection with medication errors, namely carboplatin and cyclophosphamide as anticancer drugs pantoprazole as non-anticancer drug.

CONCLUSION

Frequently occurring medication errors in the field of oncology were identified, facilitating the development of specific recommendations for action and prevention strategies. The implementation of an electronic prescription software is particularly recommended for the avoidance of dosage errors in chemotherapy.

Computer programs used in the field of hospital pharmacy for the management of dangerous drugs: systematic review of literature

Background

This review wants to highlight the importance of computer programs used to control the steps in the management of dangerous drugs. It must be taken into account that there are phases in the process of handling dangerous medicines in pharmacy services that pose a risk to the healthcare personnel who handle them. Objective: To review the scientific literature to determine what computer programs have been used in the field of hospital pharmacy for the management of dangerous drugs (HDs).

Methods

The following electronic databases were searched from inception to July 30, 2021: MEDLINE (via PubMed), Embase, Cochrane Library, Scopus, Web of Science, Latin American and Caribbean Literature in Health Sciences (LILACS) and Medicine in Spanish (MEDES). The following terms were used in the search strategy: "Antineoplastic Agents," "Cytostatic Agents," "Hazardous Substances," "Medical Informatics Applications," "Mobile Applications," "Software," "Software Design," and "Pharmacy Service, Hospital."

Results

A total of 104 studies were retrieved form the databases, and 18 additional studies were obtained by manually searching the reference lists of the included studies and by consulting experts. Once the inclusion and exclusion criteria were applied, 26 studies were ultimately included in this review. Most of the applications described in the included studies were used for the management of antineoplastic drugs. The most commonly controlled stage was electronic prescription; 18 studies and 7 interventions carried out in the preparation stage focused on evaluating the accuracy of chemotherapy preparations.

Conclusion

Antineoplastic electronic prescription software was the most widely implemented software at the hospital level. No software was found to control the entire HD process. Only one of the selected studies measured safety events in workers who handle HDs. Moreover, health personnel were found to be satisfied with the implementation of this type of technology for daily work with these medications. All studies reviewed herein considered patient safety as their final objective. However, none of the studies evaluated the risk of HD exposure among workers.

VicTAG chemotherapy audit toolkit: Improving chemotherapy quality and safety

OBJECTIVE

Off-protocol prescribing of systemic anti-cancer therapy (SACT) can lead to concerns about effectiveness of patient care. To identify variations in practice, a toolkit was developed for health services to address patient safety and the risk of sub-optimal outcomes for patients.

DATA SOURCES

Following significant incidents with SACT in South Australia and New South Wales, the Department of Health and Human Services, Victoria (the department) conducted an assessment of Victorian public health services to understand current practice regarding SACT protocol governance. A literature review examining SACT auditing was also undertaken to guide improvements. A department supported Chemotherapy Audit Toolkit (CAT) was created for implementation at public hospitals in Victoria. A post-implementation survey was done on uptake and issue identification.

DATA SUMMARY

An initial assessment showed that 27% of Victorian public health services were undertaking retrospective review of SACT dosing, which was targeted for improvement. The literature review identified little guidance, however an audit of current sector practices found several audit methodologies. A process that involved audits by health services assessing their own practice was adopted. The toolkit was developed and piloted with health services. A post-implementation survey showed that 20% of services were using the toolkit, 35% were implementing the toolkit and 45% did not use the toolkit.

CONCLUSIONS

The VicTAG CAT has been adopted by more than half of Victorian public health services and is being used to influence prescribing. Implementation of the toolkit has been affected by resource reallocation due to the COVID-19 pandemic. The CAT is available online.

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.

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review

Purpose

Computerised prescriber (or physician) order entry (CPOE) implementation is one of the strategies to reduce medication errors. The extent to which CPOE influences the incidence of chemotherapy-related medication errors (CMEs) was not previously collated and systematically reviewed. Hence, this study was designed to collect, collate, and systematically review studies to evaluate the effect of CPOE on the incidence of CMEs.

Methods

A search was performed of four databases from 1 January 1995 until 1 August 2019. English-language studies evaluating the effect of CPOE on CMEs were selected as per inclusion and exclusion criteria. The total CMEs normalised to total prescriptions pre- and post-CPOE were extracted and collated to perform a meta-analysis using the ‘meta’ package in R. The systematic review was registered with PROSPERO CRD42018104220.

Results

The database search identified 1621 studies. After screening, 19 studies were selected for full-text review, of which 11 studies fulfilled the selection criteria. The meta-analysis of eight studies with a random effects model showed a risk ratio of 0.19 (95% confidence interval: 0.08–0.44) favouring CPOE (I² = 99%).

Conclusion

The studies have shown consistent reduction in CMEs after CPOE implementation, except one study that showed an increase in CMEs. The random effects model in the meta-analysis of eight studies showed that CPOE implementation reduced CMEs by 81%.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-021-03099-9.

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.

A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice

BACKGROUND

Electronic health records are central to cancer care delivery. Electronic clinical decision support (CDS) systems can potentially improve cancer care quality and safety. However, little is known regarding the use of CDS systems in clinical oncology and their impact on patient outcomes.

METHODS

A systematic review of peer-reviewed studies was performed to evaluate clinically relevant outcomes related to the use of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. Peer-reviewed studies published from 1995 through 2016 were included if they assessed clinical outcomes, patient-reported outcomes (PROs), costs, or care delivery process measures.

RESULTS

Electronic database searches yielded 2,439 potentially eligible papers, with 24 studies included after final review. Most studies used an uncontrolled, pre-post intervention design. A total of 23 studies reported improvement in key study outcomes with use of oncology CDS systems, and 12 studies assessing the systems for computerized chemotherapy order entry demonstrated reductions in prescribing error rates, medication-related safety events, and workflow interruptions. The remaining studies examined oncology clinical pathways, guideline adherence, systems for collection and communication of PROs, and prescriber alerts.

CONCLUSIONS

There is a paucity of data evaluating clinically relevant outcomes of CDS system implementation in oncology care. Currently available data suggest that these systems can have a positive impact on the quality of cancer care delivery. However, there is a critical need to rigorously evaluate CDS systems in oncology to better understand how they can be implemented to improve patient outcomes.

Healthcare professionals' attitudes of implementing a chemotherapy electronic prescribing system: A mixed methods study

PURPOSE

Recent research has investigated the attitudes of healthcare professionals when implementing electronic healthcare systems such as electronic medical records or electronic prescribing in primary care. There is limited research on implementation of electronic prescribing in secondary care and no published research exploring implementation of systemic-anticancer therapy (includes chemotherapy, TKIs, monoclonal antibodies, etc) electronic prescribing. By considering what attitudes healthcare professionals had towards the implementation of systemic-anticancer therapy (SACT) electronic prescribing systems, recommendations could be developed and used to aid successful future implementations.

METHODS

This mixed methods study was in three phases. The first phase was a qualitative exploration of attitudes of healthcare professionals towards the implementation of a systemic-anticancer therapy electronic prescribing system, with the development of a questionnaire based on these findings. This was followed by a quantitative second phase where the results from the questionnaire were used to assess if the qualitative results could be generalised to a larger population. Further progression in phase three looked at developing recommendations based on the factors found in order to aid future implementations for hospitals.

RESULTS

Thirteen factors were found relating to attitudes of healthcare staff when implementing systemic-anticancer therapy electronic prescribing. Nine of these factors were cited by other researchers when implementing other electronic healthcare systems. Four factors appeared to be specific to systemic-anticancer therapy electronic prescribing implementations. Nineteen recommendations were proposed when implementing a systemic-anticancer therapy electronic prescribing system.

CONCLUSION

This is the first study, to our knowledge, to examine the attitudes of healthcare professionals when implementing a systemic-anticancer therapy electronic prescribing system and the first to define important factors and list recommendations to manage these.

Medication safety incidents in paediatric oncology after electronic medication management system implementation

Objective

To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports.

Methods

We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18‐month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication‐related and EMM‐related incidents and carried out a content analysis to identify patterns.

Results

We found ~79% (n = 651) of incidents were medication‐related and, of these, ~45% (n = 294) were EMM‐related. Medication‐related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM‐related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features.

Conclusions

Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high‐risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.

Chemotherapy medication errors

Although chemotherapy is a well established treatment modality, chemotherapy errors represent a potentially serious risk of patient harm. We reviewed published research from 1980 to 2017 to understand the extent and nature of medication errors in cancer chemotherapy, and to identify effective interventions to help prevent mistakes. Chemotherapy errors occur at a rate of about one to four per 1000 orders, affect at least 1-3% of adult and paediatric oncology patients, and occur at all stages of the medication use process. Oral chemotherapy use is a particular area of growing risk. Our knowledge of chemotherapy errors is drawn primarily from single-institution studies at university hospitals and referral centres, with a particular focus on prescription orders and pharmacy practices. Although the heterogeneity of research methods and measures used in these studies limits our understanding of this issue, the rate of chemotherapy error-related injuries is generally lower than those seen in comparable studies of general medical patients. Although many interventions show promise in reducing chemotherapy errors, most have little empirical support. Additional research is needed to understand and to mitigate the risk of chemotherapy medication errors.

Implementation of an integrated computerized prescriber order-entry system for chemotherapy in a multisite safety-net health system

PURPOSE

The development of a computerized prescriber order-entry (CPOE) system for chemotherapy in a multisite safety-net health system and the challenges to its successful implementation are described.

SUMMARY

Before CPOE for chemotherapy was first implemented and embedded in the electronic medical record system of Harris Health System (HHS), pharmacy personnel relied on regimen-specific preprinted order sets. However, due to differences in practice styles and workflow logistics, the paper orders across the 3 facilities were mostly site specific, with varying clinical content. Many of these order sets had not been approved by the oncology subcommittee. In addition, disparities in clinical knowledge and lack of communication contributed to inconsistencies in order set development. Led by medical directors from medical oncology departments at the 3 facilities, pharmacy administrators, and information technology representatives, HHS committed resources to supporting the adoption and use of a CPOE system for chemotherapy. Five practical lessons of broad applicability have been learned: engagement of interprofessional stakeholders, optimization of workflow before CPOE implementation, requirement of verification tool for CPOE, consolidation of protocols, and commitment to ongoing training and support. Evaluation of the CPOE system demonstrated a systemwide reduction in medication errors by 75% (p < 0.05). Satisfaction with the CPOE system varied among sites and was unchanged institutionwide 6 months after the CPOE implementation.

CONCLUSION

The development and implementation of CPOE for chemotherapy at a multisite safety-net health system created opportunities to optimize patient care and reduce variations through interprofessional collaborations. Initial evaluation suggested that CPOE reduced the medication-order error rate and improved user satisfaction in 1 of 3 facilities.

Effects of health information technology on patient outcomes: a systematic review

OBJECTIVE

To systematically review studies assessing the effects of health information technology (health IT) on patient safety outcomes.

MATERIALS AND METHODS

The authors employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement methods. MEDLINE, Cumulative Index to Nursing Allied Health (CINAHL), EMBASE, and Cochrane Library databases, from 2001 to June 2012, were searched. Descriptive and comparative studies were included that involved use of health IT in a clinical setting and measured effects on patient safety outcomes.

RESULTS

Data on setting, subjects, information technology implemented, and type of patient safety outcomes were all abstracted. The quality of the studies was evaluated by 2 independent reviewers (scored from 0 to 10). A total of 69 studies met inclusion criteria. Quality scores ranged from 1 to 9. There were 25 (36%) studies that found benefit of health IT on direct patient safety outcomes for the primary outcome measured, 43 (62%) studies that either had non-significant or mixed findings, and 1 (1%) study for which health IT had a detrimental effect. Neither the quality of the studies nor the rate of randomized control trials performed changed over time. Most studies that demonstrated a positive benefit of health IT on direct patient safety outcomes were inpatient, single-center, and either cohort or observational trials studying clinical decision support or computerized provider order entry.

DISCUSSION AND CONCLUSION

Many areas of health IT application remain understudied and the majority of studies have non-significant or mixed findings. Our study suggests that larger, higher quality studies need to be conducted, particularly in the long-term care and ambulatory care settings.

Medication errors in chemotherapy preparation and administration: a survey conducted among oncology nurses in Turkey

BACKGROUND

Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience.

MATERIALS AND METHODS

This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data.

RESULTS

Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%).

CONCLUSIONS

Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

Chemotherapy e-prescribing: opportunities and challenges

Chemotherapy drugs are characterized by low therapeutic indices and significant toxicities at clinically prescribed doses, raising serious issues of drug safety. The safety of the chemotherapy medication use process is further challenged by regimen complexity and need to tailor treatment to patient status. Errors that occur during chemotherapy prescribing are associated with serious and life-threatening outcomes. Computerized provider order entry (CPOE) systems were shown to reduce overall medication errors in ambulatory and inpatient settings. The adoption of chemotherapy CPOE is lagging due to financial cost and cultural and technological challenges. Institutions that adopted infusional or oral chemotherapy electronic prescribing modified existing CPOE systems to allow chemotherapy prescribing, implemented chemotherapy-specific CPOE systems, or developed home-grown chemotherapy electronic prescribing programs. Implementation of chemotherapy electronic prescribing was associated with a significant reduction in the risk of prescribing errors, most significantly dose calculation and adjustment errors. In certain cases, implementation of chemotherapy CPOE was shown to improve the chemotherapy use process. The implementation of chemotherapy CPOE may increase the risk of new types of errors, especially if processes are not redesigned and adapted to CPOE. Organizations aiming to implement chemotherapy CPOE should pursue a multidisciplinary approach engaging all stakeholders to guide system selection and implementation. Following implementation, organizations should develop and use a risk assessment process to identify and evaluate unanticipated consequences and CPOE-generated errors. The results of these analyses should serve to further enhance the chemotherapy electronic prescribing process and improve the quality and safety of cancer care.

Integrating mHealth in Oncology: Experience in the Province of Trento

BACKGROUND

The potential benefits of the introduction of electronic and mobile health (mHealth) information technologies, to support the safe delivery of intravenous chemotherapy or oral anticancer therapies, could be exponential in the context of a highly integrated computerized system.

OBJECTIVE

Here we describe a safe therapy mobile (STM) system for the safe delivery of intravenous chemotherapy, and a home monitoring system for monitoring and managing toxicity and improving adherence in patients receiving oral anticancer therapies at home.

METHODS

The STM system is fully integrated with the electronic oncological patient record. After the prescription of chemotherapy, specific barcodes are automatically associated with the patient and each drug, and a bedside barcode reader checks the patient, nurse, infusion bag, and drug sequence in order to trace the entire administration process, which is then entered in the patient's record. The usability and acceptability of the system was investigated by means of a modified questionnaire administered to nurses. The home monitoring system consists of a mobile phone or tablet diary app, which allows patients to record their state of health, the medications taken, their side effects, and a Web dashboard that allows health professionals to check the patient data and monitor toxicity and treatment adherence. A built-in rule-based alarm module notifies health care professionals of critical conditions. Initially developed for chronic patients, the system has been subsequently customized in order to monitor home treatments with capecitabine or sunitinib in cancer patients (Onco-TreC).

RESULTS

The STM system never failed to match the patient/nurse/drug sequence association correctly, and proved to be accurate and reliable in tracing and recording the entire administration process. The questionnaires revealed that the users were generally satisfied and had a positive perception of the system's usefulness and ease of use, and the quality of their working lives. The pilot studies with the home monitoring system with 43 chronic patients have shown that the approach is reliable and useful for clinicians and patients, but it is also necessary to pay attention to the expectations that mHealth solutions may raise in users. The Onco-TreC version has been successfully laboratory tested, and is now ready for validation.

CONCLUSIONS

The STM and Onco-TreC systems are fully integrated with our complex and composite information system, which guarantees privacy, security, interoperability, and real-time communications between patients and health professionals. They need to be validated in order to confirm their positive contribution to the safer administration of anticancer drugs.

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use

BACKGROUND

Chemotherapy is an effective treatment in the fight against many cancers. Medication errors in oncology can be particularly serious given the narrow therapeutic window of antineoplastic drugs and their high toxicities. Computerized prescriber order entry (cpoe) has consistently been shown to reduce medication errors and adverse drug events in various settings, but its use in the oncology setting has not been well established. To gain a better understanding of the meaningful use of cpoe systems in the outpatient chemotherapy setting, we undertook a systematic review of systemic therapy cpoe.

METHODS

A province-wide expert panel consisting of clinical experts, health information professionals, and specialists in human factors design provided guidance in the development of the research questions, search terms, databases, and inclusion criteria. The systematic review was undertaken by a core team consisting of a medical oncologist, nurse, pharmacist, and methodologist. The medline, embase, cinahl, and compendex databases were searched for relevant evidence.

RESULTS

The database searches resulted in 5642 hits, of which 9 met the inclusion criteria and were retained. In the oncology setting, cpoe systems generally reduce chemotherapy medication errors; however, specific types of errors increase with the use of cpoe. These systems affect practice both positively and negatively with respect to time, workload, and productivity.

CONCLUSIONS

Despite the paucity of oncology-specific research, cpoe should be used in outpatient chemotherapy delivery to reduce chemotherapy-related medication errors. Adoption by clinicians will be enhanced by cpoe processes that complement current practice and workflow processes.

Does applying technology throughout the medication use process improve patient safety with antineoplastics?

PURPOSE

Medical errors, in particular medication errors, continue to be a troublesome factor in the delivery of safe and effective patient care. Antineoplastic agents represent a group of medications highly susceptible to medication errors due to their complex regimens and narrow therapeutic indices. As the majority of these medication errors are frequently associated with breakdowns in poorly defined systems, developing technologies and evolving workflows seem to be a logical approach to provide added safeguards against medication errors.

SUMMARY

This article will review both the pros and cons of today's technologies and their ability to simplify the medication use process, reduce medication errors, improve documentation, improve healthcare costs and increase provider efficiency as relates to the use of antineoplastic therapy throughout the medication use process. Several technologies, mainly computerized provider order entry (CPOE), barcode medication administration (BCMA), smart pumps, electronic medication administration record (eMAR), and telepharmacy, have been well described and proven to reduce medication errors, improve adherence to quality metrics, and/or improve healthcare costs in a broad scope of patients. The utilization of these technologies during antineoplastic therapy is weak at best and lacking for most. Specific to the antineoplastic medication use system, the only technology with data to adequately support a claim of reduced medication errors is CPOE. In addition to the benefits these technologies can provide, it is also important to recognize their potential to induce new types of errors and inefficiencies which can negatively impact patient care.

CONCLUSION

The utilization of technology reduces but does not eliminate the potential for error. The evidence base to support technology in preventing medication errors is limited in general but even more deficient in the realm of antineoplastic therapy. Though CPOE has the best evidence to support its use in the antineoplastic population, benefit from many other technologies may have to be inferred based on data from other patient populations. As health systems begin to widely adopt and implement new technologies it is important to critically assess their effectiveness in improving patient safety.

Assessment of efficiency and safety of the comprehensive Chemotherapy Assistance Program for ordering oncology medications

PURPOSE

To assess whether the newly developed Comprehensive Chemotherapy Assistance Program (CAP) decreases errors and increases performance efficiency in ordering oncology medications as compared to the existing Computerized Physician Order Entry (CPOE) system, the Order Communication System (OCS).

METHODS

All chemotherapy prescriptions ordered using OCS and CAP systems during the first year of CAP implementation were prospectively analyzed to identify near-miss cases. The efficiency outcomes were determined in a trial setting with eight predefined hypothetical chemotherapy regimens, each with four measures of the average time, movement distance on the screen, maximum input interval time, and number of mouse or keystrokes per order. A total of 14 physicians participated in the study, and each regimen was ordered twice, once using CAP and once using OCS.

RESULTS

For all near-miss types, CAP orders showed significant improvements as compared with OCS orders (p<0.0001). For CAP orders, incorrect dose and agent errors were reduced by 43.9% and 31.6%, respectively. Compared with OCS orders, regimen defects, drug omissions, and incorrect data input errors were reduced by more than 70% for CAP orders. For all four efficiency measures, a statistically significant competence was identified when physicians ordered a chemotherapy prescription with CAP as compared with OCS (p<0.0001).

CONCLUSIONS

These results demonstrate the superiority of CAP over the existing CPOE system for ordering oncology medications with regard to safety and efficiency.

Drug administration error related to computerized prescribing

Introduction. One of the main reasons for the implementation of computer-based prescribing was to reduce medication errors. However, the risk has not fallen to zero and new kinds of errors have been detected.

Setting. The following case relates one of these medication errors involving a preparation of vincristine. This antineoplastic drug was injected to a patient via a subcutaneous route of administration instead of an intravenous bolus injection.

Results. Consequently, a cutaneous erythema appeared. This incident resulted from an error in the programming of the administration route of the protocol operated by a pharmacist and a physician. The pharmacist, who was responsible for the validation of the computerized medical order and then for the compounding and the dispensing of the drug, did not detect the error.

Conclusion. This case highlights the need of improved and irreproachable therapeutic protocols. Recorded in a database, they must be validated pharmaceutically and medicinally to secure computer-based prescribing, drug handling, dispensing, and administering of the antineoplastic drugs. Even if the pharmaceutical analysis of prescriptions is made easier with computerization, we encourage the training of nurses and the evaluation of their knowledge as well as the necessity for pharmacists to learn to detect new kinds of errors and to verify periodically protocols.