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Reduce administration errors while working with cytotoxic drugs

Whilst chemotherapy is a well-established treatment for oncology patients, these cytotoxic drugs still carry a significant risk of causing adverse effects and harm. This risk is amplified by the narrow therapeutic index of many drugs, and the fact that patients are often frail or immunosuppressed.

Misadministration of these drugs could result in significant toxicity. Therefore, prevention of errors during the administration stage of chemotherapy is of paramount importance for oncology nurses.

Errors can occur at any stage of the oncology treatment pathway, however the administration phase is an area particularly prone to risk. One study investigating errors as a proportion of total potential errors reported 27.3% occurring in the administration phase of oncology.1Another study concluded many of the errors that occur in the administration phase of oncology are preventable.2

There are strategies and technologies that can be adopted to improve accuracy and reduce the incidence of errors when administering chemotherapy drugs. In this article, we will first explore the types, causes and impact of administration errors within oncology, before discussing solutions to reduce them and improve oncology safety.

Most common error types

A medication administration error can be defined as “any difference between what the patient received or was supposed to receive and what the prescriber intended in the original order.”3

Below are common error types that a nurse may be either directly or indirectly responsible for at the point of oncology drug administration. An indirect error may be, for example, an error earlier in the drug preparation process by pharmacy, and therefore the nurse is indirectly responsible for at the point of drug administration. (It is worth noting that while nurses still need to double check the prescription, some errors originating in the prescribing and compounding phases may be much more difficult for the nurse to identify).

Administering the wrong drug or an incorrectly prepared compound: this can be a direct or indirect error. It may be a result of a prescribing or compounding error earlier in the process, which could be undetectable by the nurse. However, it also includes a nurse administering correctly prepared medication to the wrong patient, or administering an expired medication, both of which are detectable by the nurse.

Infusion rate errors, for example, giving a drug intended to be infused over an extended period as an IV push. IV infusion programming errors can be especially dangerous.4Many of the immunotherapy agents require complex programming due to the risk of infusion reactions if given too fast.

Sequencing errors: a 2015 study identified non-compliance with administration sequences as the second most common error during the chemotherapy preparation and administration process. 50.5% of nurses reported that this occurred at least once during the study period.5

Other types of common administration errors include:

  • Omission of drugs or supporting agents, e.g., hydration
  • Incorrect route, e.g., intravenous instead of subcutaneous delivery
  • Administration of contra-indicated drugs, e.g., where the patient is allergic
  • Failure to account for interactions with other medication

Key causes of administration errors

Complex administration processes

The error rate for IVs is double that of oral medications.6The chemotherapy drug administration process is often long and complex, with many steps before the medication is delivered to the patient. Treatment regimens typically involve several chemotherapeutic and supportive agents, many of which require individualised dosing based on factors such as body surface area and renal function. Drugs can be administered by a variety of routes, and at different rates.

The delivery of an oncology treatment regimen at any one administration session can take several hours and can involve more than one nurse during a given regimen. The complex and dynamic nature of chemotherapy administration makes the process vulnerable to human error at every stage, adding an extra layer of stress to an already burdened workforce of oncology nurses.

Complex administration processes

Paper-based workflows and unconnected systems

Many organisations still use paper files for recording and transferring patient data, which are at risk of being misplaced or incomplete, whilst information relayed during phone calls can be easily misinterpreted or forgotten. Even when software systems are in place to manage patient data, they may not be integrated, causing interruptions in the flow of data, fragmented communication and inefficiencies. This can result in a nurse not having accurate, up-to-date information about a patient and their therapy plan at the point of administration, which could have an impact on patient safety.

Additionally, the use of handwritten prescriptions can result in illegibility issues; the nurse could misread a poorly written or illegible prescription, resulting in an administration error.

Look-alike, sound-alike medication

Recent research has found that look-alike, sound-alike medications make up from 6.2% to 14.7% of all medication errors7. Many cancer drugs look very similar, often colourless liquids presented in similar-looking bags. Many drug names are also similar, and potentially easy to mix up when working under pressure.

Heavy workloads and low staffing levels

A 2015 survey of oncology nurses identified heavy workload (49.7%) and insufficient numbers of staff (36.5%) as the main underlying causes of chemotherapy administration errors5.

The impact of errors when administering chemotherapy drugs

Patient harm

The level of harm a patient experiences resulting from the incorrect administration of a cytotoxic drug will depend on a variety of factors such as the drug given, the patient’s health status, whether the error was identified at the time and steps taken to reduce the impact of it. There is a wide range of potential short and/or long-term adverse effects they may encounter, such as infusion reactions, vomiting and diarrhoea, damage to the respiratory, renal, cardiac and nervous systems, and many more. It can even lead to death.

Additionally, not only can harm from medication errors be distressing to the patient, but it can also be very distressing to the patient’s relatives and the member(s) of staff involved in the error.

Financial implications

Medication errors can have significant financial implications for healthcare organisations. This includes the expense of investigating the error, the possible requirement for additional treatment and resources to correct harm done by the error, the need to extend hospital stay, litigation claims, and more.

A 2011 study on chemotherapy in hospitalised patients showed that 449 errors generated an additional cost of €100,000 and if they had remained undetected, would have generated 216 additional days of hospitalisation.8Error prevention, therefore, means reduced costs.

Reducing administration errors

Computerised Physician Order Entry (CPOE)

Some administration errors could be avoided by replacing handwritten prescriptions with electronic versions. This reduces the risk of illegible handwriting leading to mistakes. The adoption of a CPOE system such as BD Cato™ Prescribe*, which also have built-in decision support tools, can help the physician to prescribe the correct treatment for a patient, for example through automatic dose calculations and prebuilt protocols. The technology also improves communications by standardising nurse-nurse and nurse-physician contacts regarding medication administration.

Computerised Physician Order Entry (CPOE)

Barcode medication administration (BCMA)

Barcode medication administration (BCMA) is a simple digital documentation, checking and tracking solution used by nurses to help ensure the 5 rights of medication administration are achieved:

Achieving the 5Rs with BD Cato™ ReadyMed

BD Cato™ ReadyMed is a documentation, checking and tracking app that helps oncology nurses achieve the 5Rs of patient safety during drug administration:

 
 
 

Right
patient

 

Right
medication

 

Right
dose

 

Right
time

 

Right
route

 

A BCMA system can remove many of the uncertainties, inaccuracies and communication breakdowns associated with manual and paper-based administration processes.

A 2018 study of 715 patients at the Principe de Asturias University Hospital in Madrid found that ‘the use of a BCMA system reduced the incidence and severity of errors in medication administration in the onco-haematology hospital.’9The paper also notes that ‘BCMA is a useful technology to check the five rights of medication administration in the oncohaematology day hospital and could help nurses increase the time spent on direct patient care activities.’9

BD Cato™ ReadyMed is a BCMA system. The barcode on the patient’s chemotherapy preparation is produced by BD Cato™ during compounding, while the Hospital Information System (HIS) produces the barcode on the patient’s wristband. Due to BD Cato™ and BD Cato™ ReadyMed interfacing with the HIS, the treatment can be confirmed as being correct for that patient, and the nurse can proceed to administer it. Oncology nurses can therefore be confident that the correct drug is being administered to the right patient with a simple scan. And due to automated verification, it negates the need for a second nurse check, helping to free up nurse time.

Additional error-prevention features include:

  • BD Cato™ ReadyMed guides nurses as to which medication to administer first, giving soft warnings for time-linked medications administered in the wrong sequence.
  • BD Cato™ ReadyMed gives real-time updates on medication amendments. When medication is cancelled or amended, the system will alert the user with a hard-stop if the barcode is scanned, helping to prevent the incorrect medication being administered.

BD Cato™ ReadyMed enables paperless documentation of the administration process, standardises procedures, improves traceability and reduces delays for oncology nurses.

When BD Cato™ ReadyMed was introduced into the oncology day unit at East Tallin Central Hospital in Estonia in 2019, staff reported that it reduced the risks associated with IV administration errors, despite an increase in the number of chemotherapy treatments being delivered at the time10. They also reported that BD Cato™ ReadyMed saved 3 hours 24 minutes of nursing time daily.

Errors can occur at any stage of the oncology treatment pathway, with 54% of medication errors occurring during administration3. However, most of these administration errors could be prevented by introducing technology and systems that embed error prevention rather than relying on checking procedures that, however diligent, are still not fully effective.

Summary

Errors can occur at any stage of the oncology treatment pathway, however identifying errors at the point of administration are critical, as this is the last opportunity to prevent them reaching the patient. Many of these administration errors could be prevented by introducing technology and systems that embed error prevention into the process, rather than relying on manual checking procedures that carry the risk of human error.

Unmistakably BD Oncology.

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