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Quality Improvement Projects Aim at Reducing Prescribing Errors for Chemotherapy

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Key Points

  • The key to improving completion of intravenous chemotherapy order forms was one-on-one education for physicians.
  • Other interventions included using same-day laboratory work, standardizing laboratory parameters, and educating nurses not to accept orders with deviations.
  • To address deficiencies in the oral chemotherapy ordering process, the electronic medical system was used to route orders by treating providers to an oncology-specific outpatient pharmacist.
  • The pharmacist reviewed the form and routed recommendations regarding dosing, potential drug-drug interactions, and monitoring recommendations to the prescribing provider. 

Two quality improvement projects described by Bryant-Bova in the Journal of Oncology Practiceresulted in reduced errors in prescribing intravenous and oral chemotherapy.

A project at The University of Texas Medical Branch at Galveston outpatient infusion centers first identified 15 different types of deviations on chemotherapy order forms and then instituted educational and process interventions. The highest rate of deviations (40%) resulted from laboratory values not being added to the form within 7 days before starting chemotherapy infusion and the second-highest rate (14%) was the omission of the physician’s name and page number on the form.

‘The Key to Improvement’

“Interventions consisted of educating physicians on entering complete information on orders, instituting same-day laboratory work on the day of the physician’s visit, standardizing laboratory parameters, performing audits of the order forms manually, and educating nurses on not accepting orders with deviations,” Jill N. Bryant-Bova, MD, explained. “Before the intervention, 70.1% of the chemotherapy order forms had at least one deviation. After 5 months of interventions, there was a reduction of 19% in the number of order forms with at least one deviation. Follow-up at 6 months and 1 year showed continuing reductions in the number of chemotherapy orders with at least one deviation,” Dr. Bryant-Bova reported.

“The key to improvement in ensuring that all information was included in the chemotherapy order form was the one-on-one education provided to the physicians. The process of educating both physicians and nursing staff continued after the project ended,” Dr. Bryant-Bova added. “Physicians remain receptive to education and are cognizant of the deviations in their orders. They have made adjustments to their process of writing orders before submitting them to the nurses. Nurses became increasingly comfortable with speaking up when deviations were discovered in the chemotherapy orders, and they returned the order forms to the appropriate physician for correction before advancing to the next step in the process.”

The Next Steps

Dr. Bryant-Bova listed several next steps in the chemotherapy ordering process improvement program.

  • Implement interventions in the inpatient care setting.
  • Modify the chemotherapy checklist to reflect an acceptable standardized order form.
  • Eliminate distractions for the pharmacist or nurse while they are reviewing order forms.
  • Accelerate the implementation of a computerized physician ordering system specific to chemotherapy.
  • Request that the electronic health record provide separate tabs for chemotherapy orders and chemotherapy administration so that chemotherapy cycles can be easily tracked.

Similar Risks for Oral Agents

Oral chemotherapy agents “pose many of the same risks as intravenous agents,” according to a report of a quality improvement project aimed at improving oral chemotherapy safety at Abramson Cancer Center (ACC), University of Pennsylvania, Philadelphia. Observing the process then in place for the review of chemotherapy prescriptions, a multidisciplinary team, including oncologists, advanced-practice providers, and pharmacists, “learned that oncology-specific ACC pharmacists reviewed all outpatient IV chemotherapy before its administration, but they were not involved in the review of outpatient oral chemotherapy prescriptions. In general, the only pharmacist who reviewed the oral chemotherapy prescription was a retail or specialty pharmacist who may not have access to vital patient information, such as recent laboratory test results or a current medication list for the patient.” In addition, retail pharmacists “may lack oncology-related pharmacology training, and they may not be familiar with infrequently prescribed oral chemotherapy,” the team noted.

“To address these deficiencies, we used our electronic medical system to route oral chemotherapy orders placed by treating providers to an oncology-specific outpatient pharmacist at the Abramson Cancer Center for review,” the authors stated. Chemotherapy safety standards updated in 2013 by ASCO in collaboration with the Oncology Nursing Society to specifically include oral chemotherapy were used to develop the review form used by the pharmacist. The form takes into account “pertinent information such as body surface area calculations, current medication list, and potential drug-drug interactions. Renal and hepatic dosing adjustments and additional monitoring required were reported by using Food and Drug Administration labeling recommendations,” the authors explained.

35% Intervention Rate

“Pharmacists completed this form, placed it into our electronic medical record, and subsequently routed the note to the prescribing provider. Pharmacists contacted physicians directly at their own discretion regarding dosing and/or monitoring recommendations or about potential drug-drug interactions.” The intervention was used first in the treatment of patients with melanoma and then expanded to include patients with breast cancer and lung cancer.

Pharmacists reviewed 63 oral chemotherapy orders for 45 individual patients placed over 7 months. “No significant dosing errors were discovered,” the researchers found, but 22 (35%) orders prompted interventions. They included 1 recommendation for dosage adjustment, 9 recommendations for discontinuing an interacting drug, and 12 recommendations for additional drug monitoring.

Most Physicians Agreed With Recommendations

“In the 16 circumstances in which the provider was directly contacted, the physicians agreed with the recommendations in all cases but one,” the researchers reported. “Specific examples of pharmacists’ recommendations included echocardiographic monitoring with the prescription of trametinib, a dosage reduction of vemurafenib for a patient with concurrent liver dysfunction, increased electrocardiographic monitoring for a patient receiving concurrent dronedarone and vemurafenib, and modification of proton-pump inhibitor therapy in the setting of erlotinib and dabrafenib.”  

The pharmacists spent approximately 22 minutes per patient to comprehensively review each prescription. “Given this new workload in addition to their preexisting responsibilities,” the quality improvement team “determined that additional pharmacy staff would be needed before this protocol can be widely disseminated throughout our cancer center.” The authors reported that additional pharmacy staff positions have been created as a result of the study, with one position specifically dedicated to the review of oral chemotherapy. “Pending the hiring and training of this new staff member, we plan to make review of oral chemotherapy prescriptions a new safety standard at our institution,” the quality improvement team stated.

The study was supported by the Cancer Center Research Training Program Grant No. NCI 5-T32 CA09615-25 and the Center for Health Care Improvement and Patient Safety at the University of Pennsylvania.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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