The Case

A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy cycle of IV etoposide (daily for 3 days) and IV cisplatin (a single dose). The chemotherapy order was sent to the hospital's cancer center satellite pharmacy, where the pharmacist entered the order into the computer. She prepared the first doses of etoposide and cisplatin, which were scheduled for administration on a Friday.

Inadvertently, while transcribing the order, the pharmacist switched the duration of therapy for the two agents, entering a single dose of etoposide and 3 days of cisplatin therapy. The patient received the correct doses on the first day (since the transposition didn't affect this); however, the subsequent days' doses were incorrect. The second day of therapy fell on a Saturday, and the satellite pharmacy was closed for the weekend. Doses for day 2 of therapy were therefore prepared in a different pharmacy, by a pharmacist who did not have access to the original chemotherapy order. The weekend pharmacist instead received a computer-generated label for cisplatin, verified the dose was appropriate for the patient's body surface area, and prepared the dose without realizing the patient had already received cisplatin the day before. Thus, cisplatin was labeled and dispensed according to the incorrectly transcribed order.

When the dose reached the bedside, the patient's nurse was in a hurry and bypassed the double-check policy of having a second nurse verify the chemotherapy order prior to administration. The nursing and pharmacy medication profiles were actually on different systems, so the nursing profile reflected the original correct order while the pharmacy profile reflected the incorrectly transcribed order. The patient ultimately received a second dose of cisplatin instead of the intended dose of etoposide.

Immediately after the cisplatin had been administered, the nurse reread the original order, recognized the error, and contacted the pharmacy and physician. In subsequent days, the patient's renal function began to deteriorate, and she required hemodialysis several times during the hospitalization. Luckily, the patient recovered and no longer needed dialysis by the time of discharge.

In response to the event, the hospital established a policy requiring original chemotherapy orders to be used as a double check following initial doses and reviewed strategies to improve interoperability of the technology involved in the processing and administration of chemotherapy orders.

The Commentary

Commentary by Jason Bergsbaken, PharmD

Safe ordering and administration of chemotherapy is of the highest priority for organizations.(1) Chemotherapy errors have been reported at all points of the medication use process, including ordering, administering, and monitoring. In studies specific to chemotherapy ordering, error rates have ranged from 3% to 8.1%, with 19% to 67% of these errors causing potential patient harm.(2-5)

The American Society of Clinical Oncology and Oncology Nursing Society have published chemotherapy safety standards for ordering, preparation, and administration across the inpatient and outpatient settings for both oral and parenteral therapy.(6) These standards were first published in 2009 and most recently updated in 2016. The guidelines include four sections: (i) environment policies and procedures; (ii) treatment planning and patient education; (iii) ordering, preparing, dispensing, and administering; and (iv) monitoring after chemotherapy. These standards are meant to guide day-to-day practice and evaluate institutional workflows.

In examination of this case, gaps between safety standards and organizational workflows likely contributed to this error. One such gap was appropriate chart documentation. Before the first administration of a new chemotherapy regimen, chart documentation of the treatment plan should be readily available.(6) At minimum, such documentation should include the patient diagnosis, medication names and doses, duration of treatment, and goals of therapy. Treatment plans should be reviewed and approved by a multidisciplinary team of stakeholders, including physicians, nurses, and pharmacists, for clinical accuracy. The treatment plans should be made transparently available within an organization, either within an electronic or paper order set library. In this case, the lack of a standardized, transparent treatment plan was compounded by separate medication profile systems, which added another barrier to appropriate treatment verification.

The standards also recommend multiple layers of verification by licensed and competent individuals. Prior to chemotherapy administration, a second person approved to prepare or administer chemotherapy should perform independent verification of the treatment plan information and product preparation. This step should not be overlooked. In this case, the policy called for initial verification by the pharmacist followed by verification by two nurses. However, environmental factors like fast pace and staffing conditions caused this essential step to be bypassed.

In addition to the workflow-specific safety standards contributing to this error, there are further considerations related to the use of the electronic health record (EHR) for chemotherapy ordering. Computerized provider order entry (CPOE) has been shown to significantly reduce medication errors.(7) The use of standard electronic chemotherapy order sets in the EHR has increased steadily over the past decade and can promote standardized safe ordering practices.(8,9) General principles should be followed when implementing such a system: accuracy, standardization, automation, decision support, flexibility, workflow integration, and reliability. Additionally, it is recommended that orders can be simultaneously viewed at any time by any health care professional involved in a patient's care.(10) In this case, all staff did not have transparent simultaneous access to standardized order sets.

Despite the perception that CPOE for chemotherapy ordering is superior to paper order set alternatives, electronic ordering systems expose end-users to new and different types of errors.(11) The initial error in transcribing the order in this case may have been a "juxtaposition" error, in which the options for selecting etoposide and cisplatin were close together on the ordering screen, making it easy to accidentally enter the wrong option. Other errors unique to electronic chemotherapy order sets include inadvertent signing (i.e., providers sign for inadvertent additional medications and/or cycles of therapy) and unintentional propagation (i.e., providers make a change within treatment plan that may or may not be properly propagated to remainder of plan).(1) All staff need to be constantly vigilant and not become falsely secure and overdependent on technology by assuming the EHR will catch errors.(12) Additionally, increased reliance on the electronic system can reduce valuable face-to-face staff communication.

In summary, this case highlights the importance of maintaining best practice safety standards for chemotherapy workflows, including ordering, preparation, and administration. The use of standardized electronic treatment plans can promote safe ordering workflows, but all health care professionals must remain vigilant to promote transparency and safe ordering practices despite the multiple advantages provided by EHR capabilities.

Take-Home Points

• Best practice chemotherapy safety standards exist for safe chemotherapy ordering, preparation, and administration.
• Prior to chemotherapy administration, transparent chart documentation should be available, which includes, at minimum, the patient diagnosis, medication names and doses, duration of treatment, and goals of therapy.
• Multiple layers of verification by licensed and competent individuals are recommended prior to chemotherapy preparation and administration; a transparent system is necessary to ensure staff is available and well-equipped to perform verifications.
• Standardized ordering within the EHR can have safety advantages, but all staff must be vigilant as EHR ordering systems are fallible.

Jason Bergsbaken, PharmD
Pharmacy Coordinator, Regional Oncology Services
UW Health
Madison, WI

References

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