Guidelines on preventing errors in chemotherapy now being revised

Emphasis on oral chemotherapy

It's been over a decade since experts were invited to write specialty guidelines regarding preventing medication errors with antineoplastic agents. And now the guidelines are dated, and experts have been working on an update that includes the impact of new technology.

The American Society of Health-System Pharmacists (ASHP) published the Practice Guidelines on Preventing Errors in the Use of Antineoplastic Medications in 2001.

"One of the new technologies is computerized prescriber order entry (CPOE)," says Robert DeChristoforo, MS, FASHP, chief pharmacist at the National Institutes of Health Clinical Center in Bethesda, MD. DeChristoforo presented information about the proposed revisions at the 44th ASHP Midyear Clinical Meeting and Exhibition, held in Las Vegas, NV, Dec. 6-10, 2009.

Approximately 15% of hospitals have CPOE, and there are other new technologies like smart pumps, so the old guidelines did not include these," DeChristoforo says. "Also, the guidelines published in 2001 didn't emphasize enough of the oral products."

So DeChristoforo and co-authors added two new sections to the proposed guidelines, covering new technology and oral chemotherapy.

"We emphasize there are errors that still can be made even with a computer system," DeChristoforo says.

The guidelines still need to be peer-reviewed before they are approved.

Here is a preview look at what the proposed guideline changes suggest:

CPOE: Increasing numbers of hospitals are using CPOE, which is expected to improve medication safety.

But sometimes the new technology itself can introduce new errors, DeChristoforo says.

"For example, you can make an order entry template for a prescriber who orders a particular regimen of chemotherapy," he explains. "But if you were to make a mistake designing the template then you'd perpetuate the mistake until someone caught it."

This is an example where technology potentially could make them worse by magnifying one mistake at one time to multiple mistakes over time.

"Let's say a drug is supposed to be 3.5 mg/kg per dose, but when the template indicates 3.2 mg/kg you introduce an error," DeChristoforo says.

The revised guidelines will recommend that if a hospital pharmacist makes a template, then he or she should make sure it's double-checked by various people to ensure it's correct, he says.

When health systems set up CPOE, they should make certain these are designed with patient safety safeguards in place.

"Using the CPOE system should prevent someone from ordering the wrong route of administration or prevent the potential for a deadly mistake," DeChristoforo says.

"With CPOE the doctor has to choose the route of administration," he explains. "So if a drug could kill a patient if it's given intrathecally, then the system should be set up so the doctor can't even select the wrong route of administration."

These electronic systems can be engineered to provide safeguards that do not allow prescribers to continue with an order until it's been corrected, he adds.

"We're emphasizing that having prescribers enter information directly into a CPOE decreases errors, but the system is not foolproof," DeChristoforo says.

Conversions: "Many times chemotherapy is given by body surface area, and you need height and weight," DeChristoforo says.

"So there are times when a patient is weighed in kilograms," he explains. "Then someone enters pounds in the computer system instead of kilograms."

This weight entry error may lead to a dosing error if not detected.

One solution is for a health system to decide to use one weight and measurement system and then stick with it, avoiding the need to use conversions, DeChristoforo says.

Oral agents: "There are more oral agents that have come to the market since the first guidelines were written," DeChristoforo says. "Plus, for whatever reason, we didn't emphasize oral agents enough in the original guidelines."

New drug development has shifted more focus to oral agents with 25% of new cancer drugs in development being planned as oral chemotherapy agents, he adds.

"There's a sense among providers that since these drugs are oral, they're not as dangerous as IV medications," he adds. "But if you don't take them properly, they're still dangerous."

For example, the doses of oral medications should be independently double-checked, DeChristoforo advises.

"It's probably a good recommendation not to allow refills on prescriptions for antineoplastic drugs," he says. "The pharmacist should have access to enough information to check the dose, height, weight, body surface area, and stop/start date."

Prescribers need to teach patients not to crush or chew these products unless they're specifically told to do so, he adds.

Patient education is crucial because missed doses can have a bigger impact with these types of medications than with most drugs prescribed to patients, he adds.

"For patient education, you should provide both written and verbal education and have patients repeat key points," DeChristoforo says.