Download Promoting Medication Error Prevention Strategies Through

Promoting Medication Error Prevention Strategies Through Education
Authors: Mandeep Bains, Lynne Ferrier, Rhonda Kalyn, Tonya Ng, Sanna Pellatt
BC Cancer Agency, Pharmacy Department, British Columbia, Canada
Background/Objectives:
Results Continued:
Results Continued:
• Cancer treatment can involve complex, cyclical, multi-day, multi-drug
regimens with a potential for serious toxicity. The therapeutic index for
chemotherapy drugs is narrower that that for any other class of drugs.¹
Chemotherapy errors constitute the second most common cause of
fatal errors.²
• In British Columbia, cancer drugs are provided by six BC Cancer Agency
(BCCA) Centres and 33 regional Communities Oncology Network (CON)
hospitals, that work together to ensure BC residents receive safe,
effective cancer treatment close to home.
• BCCA performs process reviews to identify potential sources of error in
the various stages of chemotherapy preparation, delivery, and
administration. The results of these reviews, along with literature
reports of cancer drug medication errors, are used to develop process
improvements to reduce risk of future errors and to create educational
material.
• To promote consistency of care between BCCA and CON hospitals,
BCCA CON Pharmacy Educators provide education to CON hospital
pharmacy, nursing and medical staff about process improvements to
reduce errors.
Order Entry Theme: Look-Alike/Sound-Alike (LASA) Drug Selection Errors
(e.g. paclitaxel vs. paclitaxel-nab protein bound, doxorubicin vs.
doxorubicin-pegylated liposomal)
Prevention Strategies: 1) use pop-up computer alerts or ensure
computer drug selection options clearly differentiate between two
LASA drugs; 2) carry different brands of LASA drugs if available or
possible; 3) store them separately with warning labels.
Results
The slide presentation illustrated potential sources of error as identified
by ISMP pharmacy-related themes, along with corresponding BCCA
prevention strategies, process changes, and applicable online BCCA
resources. Examples of the education provided include:
Figure 3. BCCA Oral Cancer Drug Auxiliary Label List excerpt
Drug Dispensing Theme: Incorrect Drug Quantity Errors
ISMP Canada noted that supplying the wrong number of days of oral
chemotherapy was reported as the most likely to cause harm (39.3% of
harmful events studied).4
Prevention Strategies: 1) implement blister/unit-dose packaging (see
Figure 4) or calendars for multiple-strength drugs; and 2) doublecount oral chemotherapy.
Figure 4. Blister/Unit Dose Packaging
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Clinical Assessment & Communication of Changes Theme: Interval Timing
Errors
Prevention Strategies: 1) increase awareness of complex protocols; 2)
highlight BCCA strategies to make complex protocols clearer. The
example pre-printed order (PPO) in Figure 1 was used to illustrate
bolding, and a separate day 8 dose modification line to distinguish
different drug and dose options, if required, on different days.
Figure 1. Complex Orders GUAJPG PPO
Figure 6. GIAVCAP PPO INR monitoring prompt added
Drug Dispensing Theme: Auxiliary Labeling Errors
Prevention Strategy: 1) promote use of standardized auxiliary labels
to provide consistent patient information and prevent reader fatigue
from an excessive number of labels. The online BCCA tool “Oral
Cancer Drugs Auxiliary Label List” (see Figure 3) is available to sites
that do not have their own standardized list. 2) Place auxiliary labels
on drug supply bins as visual reminder for dispenser.
Design:
• Reports of errors and near misses, Institute of Safe Medication
Practices (ISMP) safety literature recommendations, and recent safetyrelated process changes were analyzed.
• BCCA error prevention strategies were categorized according to the
following ISMP Canada’s Chemotherapy Medication Error Themes³:
Clinical Assessment & Communication of Changes, Order Entry,
Dispensing, Administration, and Monitoring.
• The BCCA CON Pharmacy Educators developed the following
educational resources to present to CON hospital staff: a slide
presentation based inservice, an Error Prevention Checklist, and
referrals to related online BCCA content.
Prevention Strategies: 1) increase awareness of changes to BCCA
Protocols and PPOs to make drug interaction and INR monitoring
guidelines more prominent (see Figure 6); and 2) increase awareness
of the impact of side effects like diarrhea on drug monitoring.
CON staff were also referred to the following online BCCA resources:
• Clinical Chemotherapy Assessment and Review Checklist (Oral,
Parenteral, Intraperitoneal) [Clinical Pharmacy Guide] – this handout
provides clinical checking guidelines and error prevention tips (see
Figure 7)
• Medication Safety Learning Module [BCCA Oncology Pharmacy
Education Program] – a freely available 4 hour online self-study
module that discusses oncology medication errors in the literature,
the importance of active sharing of safety learning, and how incident
learning results in practice change.
• Patient Guide to Medication Safety – this patient handout (see Figure
8) teaches patients to play an active role in medication safety by
familiarizing themselves with their medications, and asking questions.
Figure 7. Chemotherapy Assessment and Review Checklist excerpt
2. Confirm Correct Protocol and that it Matches Clinical Indication and
Eligibility for Treatment
•Watch for red text in some online protocol names used to distinguish
between look-alike names
3. Review Medical History for Potential Interactions and Allergies
•Ensure patients are informed of interactions and required follow up (e.g.,
more frequent INR testing for warfarin interactions)
•Consider if chemotherapy adverse effects might interfere with other
medications. (e.g., diarrhea-induced prolongation of INR and possible bleeding
with warfarin)
Figure 8. BCCA Patient Guide to Medication Safety excerpt
*This Temdol sachet image is reproduced with permission of Merck Canada Inc. All rights reserved.
**All trademarks are the property of their respective owner.
Drug Administration Theme: Fluorouracil Continuous Infusion Rate Errors
Prevention Strategy: promote use of BCCA online tool “Elastomeric
Infusor Rate Error Prevention Checklist” shown in Figure 5.
Figure 5. BCCA Elastomeric Infusor Rate Error Prevention
Checklist excerpt
Conclusions:
Education about error prevention is essential for CON staff to understand
BCCA process changes and implementation procedures. BCCA Pharmacy
CON Educators will continue to liaise between CON hospitals to support
safe and consistent cancer medication delivery across BC.
Dose Assessment Theme: Maximum Dose Errors
Prevention Strategies: 1) increase awareness of maximum doses; 2)
highlight BCCA strategies to improve clarity of dose limits. The
example PPO in Figure 2 illustrates improved visibility for the
maximum dose.
Figure 2. SAVAC PPO with Vincristine Dose Cap
References:
Drug Monitoring Theme: Lack of Systematic Monitoring Process
A “Monitoring INR with Concurrent Capecitabine and Warfarin” Case
Study was used to illustrate error prevention process changes. “Patient
had been taking warfarin prior to starting capecitabine and did not have
INR monitored as frequently as needed... led to a serious complication.”5
1. Goldspiel B et al. ASHP Guidelines on Preventing Medication Errors with Chemotherapy and
Biotherapy. Am J Health Syst Pharm. 2015;72: e6-e35.
2. Phillips J et al. Retrospective analysis of mortalities associated with medication error. Am J
Health Syst Pharm. 2001 Oct 1;58(19):1835-41.
3. ISMP Canada. Medication incidents involving cancer chemotherapy agents. ISMP Canada Safety
Bulletin. 2010 March 16;10(1):1–4.
4. ISMP Canada. Preliminary results from the International Medication Safety Self Assessment for
Oncology. ISMP Canada Safety Bulletin. 2013 July 23;13(6):2-6.
5. BC Cancer Agency Systemic Therapy Update Newsletter. 2014 Dec; 17(12):3-4.
Contact: Mandeep K. Bains [email protected]