Download Leeds Cancer Centre - ePrescribing Toolkit

ePrescribing of Chemotherapy
The Leeds Experience
Julie Mansell, Lead Chemotherapy Pharmacist, Leeds Cancer
Centre
Background at Leeds Teaching Hospitals
• SJUH Opmas 1993
• Cookridge Design partners – Chemocare® 1995
• Introduced to breast cancer clinic, gradual rollout
• Cookridge site → oncology SJUH, haematology
• 60+ consultants
• 5000 patients per annum
• Oncology, haematology, BMT, trials including early phase
• Treatment given orally, day case, in-patient and ambulatory
• All chemotherapy prescribed using Chemocare®
Improved safety
2006 Journal of Quality and Safety in Healthcare
“Effect of computerisation on the quality and safety of chemotherapy
prescription”
• Oncology centre in Lausanne
• Examined chemotherapy errors before and after implementation
• Classification of errors
Major = drug name, dose, route of administration
• Before 141 errors in 940 prescriptions (19% major)
• After 6 errors in 978 prescriptions (0% major)
Error rate reduced from 15% to 0.6%
Marc Voeffray et al. Effect of computerisation on the quality and safety of chemotherapy prescription Qual. Saf. Health Care 2006;15;418-421
Complex prescribing – ideal target
• Narrow therapeutic index and highly toxic– potential for harm is great
• Wide range of doses e.g. Methotrexate 10mg to 12g/m2
• Dose, interval, route varies with tumour type
• Dosed on BSA, weight, fixed
• Several medicines in most regimens
• Supportive medicines to deliver safely
• Multiple day treatment with different medicines on different days
• BEP – Bleomycin D2, 8,15 Etoposide D1,2 3 Cisplatin D1, 2
• Modifications for myelosuppression, renal + liver impairment frequent
• Common use of acronyms
• Classes of agents with very different uses e.g.rituximab/trastuzumab
National Drivers
• Manual for Cancer Services
Rolling quality assurance programme for cancer services
Purpose - enables quality improvement both in terms of clinical
and patient outcomes
2004-2007 40% ePrescribing
• Chemotherapy Services in England: Ensuring quality and safety
National Chemotherapy Advisory Group 2009
Group established to advise DH on development + delivery of
high quality chemotherapy services
“Handwritten prescriptions for parenteral chemotherapy should
be replaced as soon as possible by pre-printed forms or,
preferably, by fully validated electronic prescribing systems”
• Chemotherapy measures 2011 11-3S-139 to 142 Electronic Prescribing
– covers criteria for system and SOP’s
Benefits and successes (1)
• Reduces prescription errors
• Legible
• Faster for complex treatment
Benefits and Successes (2)
Quality assurance
• Consistency of prescribing
• Controls access to protocol for certain diseases only
• Central control of change
• Set maximum doses/ routes that cannot be overwritten
• Reduces variation in clinical practice
• Template sign-off by consultant, 2 pharmacists
• Calculation of patient variables e.g. GFR, BSA
Benefits and Successes (3)
Pharmacy specific
• Integrated worksheet and label preparation
• Automatic dose rounding
RAPID RESPONSE REPORT NPSA/2008/RRR04
“Doses of vinca alkaloids should be prepared for use by dilution in small volume
intravenous bags, rather than in syringes”
Additional benefits
• Audit and review of practice
• Identifies case series for research projects
• SACT dataset
• Facilitates service re-design
• Improves prescribing efficiency in clinic
• Easily accessible treatment view on admission
Specific Challenges/Limitations
Reluctance/resistance to change
• Technophobes!
• Age range/ skills of staff across MDT
• Slower for simple treatments
Find Clinical and Managerial Champions
Employ national drivers
Promote additional benefits
Patience and perseverance!
Training burden
• Time consuming –start up/new staff/upgrades
• Level 1 competency (prescribing scenarios)
Employ (if possible) a designated ePrescribing lead
Specific Challenges/Limitations
Loss of knowledge
• Doses of chemotherapy never learned
• Supportive medicines not appreciated
Teach and test the basics
Errors
• ePrescribing = different errors ≠ NO errors
• If template incorrect - affects multiple patients
• Depends on quality of input e.g. 0mg/ height and weight mistakes
Foster a quality culture
Check and check again
Review common themes
Specific Challenges/Limitations
Technical challenges
• Difficult to set up templates for complex regimens
• Chronomodulation / trial dose bands
• National system – unable to make many in-house tweaks
• No administration module → paper copy for records
Be creative, but maintain safety
Future Challenges
Paper-lite
• Long established use of prescription as communication tool
• Reluctance to change
Use clinical (multi-professional) champions
Use local drivers – efficiency
Project group