chemocare the first full year 16th march 2010 1pm - 2pm steve evans gail povey with support from:...

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.


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


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


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


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)


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


Interventions form

Pharmacy encouraged to consider completing an incident/audit form


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


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.


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


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)


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?


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


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 ?????

chemocare the first full year 16th march 2010 1pm - 2pm steve evans gail povey with support from:...

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